Introduction

American health policy has spent decades arguing about who pays for services, while largely overlooking a more basic issue: What happens when there aren’t enough doctors to provide those services? As the population ages and many doctors cut back their hours or burn out, the United States is facing a serious doctor shortage. This paper explains what is driving that shortage, why unnecessary state‑level rules create a “residency trap” that blocks many foreign‑trained but now-American doctors from practicing, and how state governments could, by changing those rules, quickly bring thousands of qualified physicians into the workforce without lowering standards.

Access to a physician is a basic condition of health, stability, and opportunity. A physician shortage turns that basic condition into a question of timing: whether a patient can be seen early enough to prevent a manageable problem from becoming a crisis. This matters especially in low-income, rural, and otherwise underserved communities, where there may be few nearby providers and little practical flexibility when appointments are unavailable. Low-income, rural, and otherwise underserved patients are more likely to wait longer, travel farther, postpone or forgo care, and turn to costly emergency departments when primary care is unavailable. They are also less able to pay out of pocket or go out of network to navigate the shortage. 

The scale of this problem is easy to underestimate because standard workforce projections measure demand largely through observed use of medical care. But observed use reflects whether patients can afford care, find a nearby provider, obtain an appointment, and overcome other barriers. The Association of American Medical Colleges projects a nationwide shortfall of up to 86,000 physicians by 2036 based on current patterns of care. To put that figure in perspective, the AAMC counted 1,032,365 active physicians in the United States in 2024, making the projected gap roughly 8 percent of the active physician workforce. 

The AAMC also modeled an equity scenario in which underserved populations obtained care at rates comparable to better-served populations. Under that scenario, the nation would have needed roughly 117,000 to 203,000 additional physicians as of 2021, up to a fifth of the current workforce. In a separate 2024 survey, 57 percent of underinsured adults reported avoiding needed care because of cost. In 2023, over a quarter of American adults skipped some kind of medical treatment because they could not afford it. This matters because primary care is often where physicians first detect or manage conditions such as asthma, depression, high cholesterol, diabetes, thyroid disorders, kidney disease, infectious illnesses, and cancers identified through screening. When patients delay or skip care, these conditions may go undiagnosed or untreated, increasing the risk of preventable complications. Delayed treatment can also shift care into more expensive settings, placing the greatest burden on low-income patients.

For families in rural America, a doctor shortage means the nearest doctor for their specific illness could be hours away. In 2019, it was predicted that there would be a 23 percent decline in rural physicians by 2030 due to retirements. For people in cities, it means wait times that span months, not days or weeks. Across the country, the current average wait time for a doctor’s appointment is 31 days. 

At the same time, the United States has an underused source of physician capacity: internationally trained physicians who already live in the country. International medical graduates (IMGs) are not marginal to the American health-care system. Nearly 325,000 internationally trained physicians practice in the United States—roughly one-third of the active physician workforce—and they already provide a substantial share of care in many communities and specialties. That figure counts physicians who have already secured licensure and are practicing; it does not include additional internationally trained physicians living in the country who remain unable to obtain full licensure. The size of the existing IMG workforce therefore shows that many internationally trained physicians can meet U.S. standards, not that the licensing problem is small. Other highly qualified physicians who have completed postgraduate education and practiced independently abroad remain unable to practice at their full level because of state licensing restrictions.

These restrictions are commonly described as the “residency trap.” Under traditional pathways in most states prior to proposed alternatives in 2023, an internationally trained physician must complete one or more years of U.S.- or Canadian-accredited residency before becoming eligible for a full license, even when that physician has already completed residency or specialty training abroad and has practiced independently. 

The requirement does not apply in exactly the same way in every state, and some states recognize portions of foreign training or offer alternative pathways. Because these pathways are relatively new and differ in structure, there is not yet enough standardized evidence to compare physician supply or patient outcomes across states. But where the requirement applies, it sends experienced physicians back into a competitive residency system designed primarily to provide postgraduate training to new U.S. medical graduates right out of medical school. The system generally accommodates most current U.S. medical-school seniors, but it is not designed to provide an additional position for every qualified international medical graduate who must enter it. 

The result is a policy paradox: The United States needs more physicians, and isn’t producing them domestically; at the same time, many states require experienced foreign-trained physicians to enter the same limited training pipeline used to prepare new doctors. A physician may have years of relevant clinical experience and still need to compete for a qualifying residency position, sometimes outside the specialty in which that physician was trained. If the physician cannot secure a position, the physician cannot obtain a full license, regardless of how much training and practice has already been completed abroad, or how much more training and practice they are willing to do to prove themselves. A requirement that might be a modest educational step if positions were abundant becomes a gatekeeping barrier when the prerequisite itself is rationed.

The residency trap damages the physician pipeline in two ways: it exhausts residency slots that are already in short supply, and it forces qualified, experienced doctors to spend years repeating training needlessly. 

The one upside of problems created by regulation is that they can be solved by changing regulation. In this case, the relevant authority is primarily state-level: Where residency requirements are written into statute, state legislatures can authorize an alternative licensure pathway; medical boards can then implement it through rules governing credential review, assessment, supervision, and practice.

Removing this barrier does not mean abandoning standards or assuming that all foreign medical education is equivalent. Medical schools and training programs vary across countries, and some applicants may require additional education, supervision, or assessment. There are straightforward ways to assess the quality of a medical education. Existing safeguards include primary-source verification of medical credentials by the Educational Commission for Foreign Medical Graduates (ECFMG); confirmation that the applicant’s medical school is listed in the World Directory of Medical Schools with an ECFMG Sponsor Note for the relevant graduation year (if there is no ECFMG note, then the school is not high quality enough to qualify); U.S. licensing examinations; review of postgraduate training and professional history; and clinical evaluation by residency programs, hospitals, and state medical boards.

The relevant question is whether full repeat residency should be the default requirement for every internationally trained physician, or whether states can evaluate competence more directly in other ways. Large comparative studies have found that patients treated by internationally trained physicians experience medical outcomes comparable to those treated by U.S.-trained physicians, although these findings do not establish that every physician is equally prepared for every role.

State legislatures and medical boards can create alternative licensure pathways for qualified IMGs that recognize substantial foreign training and experience while requiring appropriate examinations, supervised practice, performance review, and disciplinary accountability. States may also choose to begin with primary care and other first-contact roles in underserved communities, where timely access can prevent health problems from becoming more serious and more expensive. 

Expanding graduate medical education remains necessary for the long-term physician workforce, but it cannot solve the near-term problem of experienced physicians who are already here but unable to practice. The following sections explain the stakes of the problem for low-income Americans, diagnose the broader shortage, explain how the residency bottleneck operates, examine the evidence on IMG safety, and develop the details of this state-level reform.

The Paradox of American Health Care

American health care embodies a strange contradiction: it delivers some of the best medical care in the world, and yet routine procedures are often out of the reach of ordinary people because it is unavailable, unaffordable, or too far away. The same system that produces cutting‑edge treatments, historic gains in cancer survival, and a haul of international prizes for medical innovation also leaves many patients waiting weeks for an appointment, skipping care altogether, or dying of conditions that are preventable in peer countries. 

In practical terms, this means that the United States has built a medical establishment that is excellent at solving hard problems once a patient is in the room, but surprisingly bad at ensuring people can get into that room in the first place.

Much of the conversation about creating a healthy citizenry and productive workforce centers on affordability. The idea is that without the fear of unexpected bills and bankruptcy, people would go to the doctor, use modern technology to heal their treatable ailments, and become even more productive community members. The idea that individual health and flourishing leads to a healthy nation is a deeply held value in our country, but this ideal is far from reality.

People avoid going to the doctor for a few key reasons, such as high costs, hopes the illness will go away on its own, and the physical discomfort of going. In that context, it can be easy to overlook that in the current medical environment, even if you can pay for it and muster the will to show up, this does not guarantee that there is a doctor there to treat you. 

That is the access problem created by a doctor shortage: demand exceeds the number of clinicians available to provide care. Patients may wait a month for an appointment. A month-long wait can mean a month without diagnosis or treatment; if follow-up visits, tests, or referrals require additional appointments, the delay can stretch into multiple months. The American Medical Association identifies physician shortages as one cause of longer waits and reduced access to care. 

Those delays can have consequences beyond unnecessary pain, and push patients into more expensive settings. In a nationally representative study of U.S. adults, patients who reported that they could not get an appointment soon enough had 45 percent higher adjusted odds of an emergency department visit, even after accounting for socioeconomic and health factors. A 2024 study of 394,424 older Medicare beneficiaries with multiple chronic conditions likewise found a higher likelihood of emergency department visits among patients receiving care in primary-care shortage areas than in non-shortage areas. 

The best outcomes are achieved when problems are caught early and treated quickly. When weeks or months pass before the patient can see a doctor, the condition has time to escalate. This means that the ailment could end up requiring a more expensive, more complex, more invasive intervention than if it had been treated promptly. In some cases, it even becomes fatal. Multiply that across communities, and these patterns produce a country where chronic illnesses are mismanaged, preventive care is skipped, and too many people use hospital emergency departments for crises that could have been avoided.

Data suggest that this is, in fact, the country we live in. The United States ranks last among ten peer high-income countries on multiple health outcome measures, including life expectancy and preventable deaths. This is despite spending nearly twice as much per capita on health care. Two-thirds of hospital emergency department visits by privately insured individuals can be handled by an urgent care center or a primary care physician. Many of these visits are for conditions that ought to have been managed or prevented in a stable primary care relationship if patients had timely access in their own communities.

If America’s low health care ranking seems like it cannot be the entire story—it isn’t. In FREOPP’s World Index of Healthcare Innovation, the U.S. ranks first in science and technology. The United States has won 103 Nobel Prizes in Medicine since the prize was started in 1901, almost half of the 229 total prizes awarded to any country in the world and significantly more than any other single country. The runner up is the United Kingdom, with only 31 awards. Clearly the United States is a leader in medical innovation. 

And so there is a paradox: The United States is a leader in innovation and technology, but it is not automatic that these innovations “trickle down” into better health outcomes for everybody. The new technology does not always improve the lives of ordinary patients.

Given the country’s world-class biomedical industry and research hospitals, one may predict that a large number of people from around the world would want to come here and practice medicine in these advanced institutions. How can there be a doctor shortage, if clinicians from all around the world are eager to work in such a technically advanced environment? Can’t the U.S. just import doctors as needed? 

Immigrants do want to come here, and they are already central to American medical progress. Of the Nobel prizes in medicine that the U.S. won, 33 percent went to immigrants. In 2024, approximately 11,000 physicians were approved on new H-1B visas (the number changes every year) to fill critical roles in hospitals.

At the federal level, Congress could consider a physician-specific H-1B cap exemption for doctors who commit to serving in federally designated shortage areas. Such a policy could help hospitals recruit additional physicians, but an H-1B visa would not override state licensure rules or itself authorize medical practice. Physicians would still need to satisfy the requirements of the state where they work, including any U.S. or Canadian postgraduate training requirement. Expanding H-1B availability could therefore complement, but not substitute for, the state licensure reform proposed here. Unless states also remove the residency barrier, a physician recruited through an expanded H-1B pathway could still be unable to practice in the state that recruited them.

In a system that clearly needs more clinicians, specific licensure rules can make it difficult for some internationally trained physicians to care for patients, whether they hope to come here or are already here. To grasp the stakes of these constraints, we first need to understand how deeply the physician shortage is already harming patients.

The Costs of Inaction

Large swaths of the country are now marked as “health care deserts”—areas where people lack adequate access to basic services like pharmacies, primary care, hospitals, hospital beds, trauma centers, or low‑cost health centers. A 2025 analysis by GoodRx estimates that roughly 80 percent of U.S. counties qualify as some type of health care desert, affecting more than 120 million people, or about one‑third of the population. 

These deserts are not evenly distributed: states with more health care deserts tend to have lower household incomes, higher uninsured rates, and poorer internet access. A national study similarly found that counties with more health care deserts were more likely to be rural and had lower median household incomes than counties with fewer deserts. The shortage therefore compounds existing financial and geographic barriers to care.

Looking ahead, the outlook is grim: one analysis projected a 23 percent decline in rural physicians by 2030 due to retirements alone, suggesting that many already fragile systems will lose even more local capacity.

Federal designations tell a similar story. The Health Resources and Services Administration uses a population-to-primary-care-physician ratio of 3,500 to 1 as a minimum benchmark for adequate supply. Communities with more than 3,500 residents per primary-care physician may qualify as Health Professional Shortage Areas (HPSAs). This is a threshold for identifying shortages rather than a target level of access.

More than 26 percent of the population lives in an area that meets these shortage criteria. In practical terms, that means tens of millions of people reside in communities the federal government itself classifies as short on primary care, and the number of such designated areas has been rising rather than falling.

International comparisons also underscore how much the United States is lagging. With about 3.7 doctors per 1,000 residents across all specialties and geographic areas, the U.S. ranks around 35th globally in physician density. It is outpaced not only by peers like Germany (about 4.5 per 1,000) and Greece (about 6.4), but also by lower-income countries including Russia, Mongolia, Kazakhstan, and Uruguay. 

Hospital capacity reflects the same pattern: the U.S. has about 2.5 acute-care hospital beds per 1,000 people, compared with an average of 4.2 among comparable wealthy countries. Japan has about 7.8 beds per 1,000 people, followed by Germany at 6.0, Switzerland at 3.6, Norway at 3.2, and France at 3.1. Only Canada and Sweden have fewer beds than the United States in this comparison. This smaller reserve can make it harder to absorb sudden surges in demand, as the COVID-19 pandemic demonstrated, and leaves the health care system vulnerable as the population ages.

The consequences show up in some of the starkest health indicators. Maternal mortality is one of the most viscerally troubling. Recent international comparisons put the U.S. maternal mortality rate at roughly 22.3 deaths per 100,000 live births—an order of magnitude higher than Norway (0), Switzerland (about 1.2), or the U.K. (about 5.5). For Black women in the United States, the rate is even more catastrophic, approaching 49.5 deaths per 100,000. These disparities have multiple causes, including medical complications, racial inequities and insurance barriers, and gaps in prenatal and postpartum care. The doctor shortage is one contributing factor: an undersupply of maternity providers and the prevalence of maternity-care deserts can make timely obstetric care more difficult to obtain, particularly in rural communities. A national study found that women living in communities with the greatest socioeconomic disadvantage had more than twice the risk of maternal death as women living in the most affluent communities during 2014–2018.

Primary care sits at the center of this access problem because in many communities, the only clinicians who can manage chronic conditions, provide preventive screenings, and recognize early warning signs are family physicians, general internists, pediatricians, and nurse practitioners working in primary care clinics. When that continuity of care is disrupted, a wide range of conditions can go undiagnosed or poorly controlled. Silent conditions such as hypertension and diabetes may progress without symptoms, while asthma and depression often require regular outpatient management to prevent serious complications. A shortage of primary-care clinicians therefore increases the likelihood that manageable problems will instead become emergencies.

That shift from routine management to emergency treatment is also expensive. Every time a poorly controlled chronic illness shows up in the emergency room, the cost is many times higher than steady, low-cost primary care, driving up personal and public spending alike. Routine primary care visits often cost under a few hundred dollars, while emergency room visits commonly exceed $1,000 and diabetes-related hospitalizations alone can run to many thousands of dollars per stay.

According to a 2013 research brief from the National Institute for Health Care Reform on privately insured patients’ emergency department use, people who reported that their primary doctor offered rapid access to advice and visits were significantly less likely to use emergency departments. The same study noted, “Indeed, nearly 60 percent of people with an urgent medical problem indicated that their problem was related to a chronic health condition—most commonly musculoskeletal problems or high-blood pressure.” Over time, this pattern hardens into a two‑tier system: People with stable primary care relationships receive continuous, preventive care, while those in primary care deserts encounter medicine mainly through emergency rooms and hospitalizations.

Today’s access problems may be only the beginning. The projections for the next decade suggest that, unless something changes, these pressures will intensify rather than ease.

The deepest gaps are expected in primary care and in already strained specialties like family medicine, pediatrics, psychiatry, emergency medicine, obstetrics, and geriatrics especially in rural areas and low‑income communities. Those are the very fields patients rely on for first‑line care, childbirth, children’s health, and mental health.

At the same time, the existing physician workforce is under acute strain. Burnout can reduce the effective supply not only when physicians leave medicine, but also when they retire early or cut back their clinical hours. In a 2023 poll, 29 percent of medical group leaders reported that their organization had experienced a physician leaving or retiring early because of burnout. Medscape’s 2024 Physician Burnout & Depression Report found that 16 percent of women physicians and 14 percent of men were considering leaving medicine because of burnout, while more than 30 percent were reducing their clinical hours. Burnout was particularly high in several specialties central to first-contact care, including emergency medicine, obstetrics and gynecology, pediatrics, and family medicine.

While burnout has many causes, staffing shortages is one of them. The Medscape report identifies job stress and long hours as major contributors to burnout, and physicians rank additional support staff among the most helpful interventions. Those findings help explain how a physician shortage can become self-reinforcing. When an understaffed practice loses a physician—or cannot recruit one—the remaining clinicians may have to absorb more patients and more complex cases with fewer colleagues and support staff. That added burden can lead physicians to reduce their hours or leave, shrinking the effective workforce further. A study of intensive-care nurses also found that burnout can spread among colleagues, suggesting that the effects of understaffing may extend beyond the physician who departs, to nurses, and potentially to other providers such as physician assistants. This cycle is particularly damaging in rural and low-income communities, where patients have fewer alternatives when local providers leave.

The costs of inaction are measured not only in who gets care, but in what kind of health care system the country is drifting toward over the next two decades. COVID‑19 offered a painful stress test. When demand surged, the U.S. health‑care system had little reserve capacity. Hospitals in hotspots ran beyond their limits. Staffing shortages contributed to delays and, in many cases, preventable deaths. A 2024 HRSA analysis found that 195,292 registered nurses—5 percent of those employed during the pandemic—left the nursing workforce between March 2020 and December 2021. Among those who left, the most commonly cited contributing factors included high-risk working conditions, burnout or overwork, and inadequate staffing. In a 2021 Jackson Physician Search survey, 21 percent of physicians said they were planning to retire early because of Covid. 

Left alone, the U.S. is on track for a physician workforce that is too small for its population, where even insured patients struggle to find doctors taking new patients. Routine procedures will become harder to obtain and more confusing to navigate. In that world, access depends less on medical need and more on location, luck, and professional connections—and it will be harder to honor the promise that everybody, regardless of income, should be able to get timely, decent care. The U.S. will slowly come to resemble systems where “knowing the right people” and “being in the right circles” largely determines whether patients can reach the right doctor for their condition, and where clinicians themselves see fewer reasons to build long careers in the communities that need them most.

Diagnosing the Doctor Shortage

What is behind this crisis in health care? Several forces are converging. The U.S. population is growing and aging, increasing demand for medical care just as a large cohort of experienced physicians approaches retirement. Burnout is also causing some doctors to leave the profession or reduce their hours before traditional retirement age. Finally, certain policies constrain both medical education and physician licensure.

Since the 2020 Census, the U.S. population has grown by more than 10 million people, reaching an estimated 341.8 million in 2025. The population is also aging: Census projections indicate that adults age 65 and older will outnumber children under 18 by 2034.

Physician retirement will add to that pressure. An AAMC workforce analysis estimated that physicians retire at a median age of roughly 67, although retirement timing varies by specialty and many physicians continue practicing beyond traditional retirement age. In 2024, 23.9 percent of active U.S. physicians were already 65 or older. The average age of a doctor in the U.S. is 54.4. 

In some specialties, the effects of retirement will be worse. In 2024, of all pulmonary disease physicians, 73.6 percent were over the age of 65. Meanwhile 36.7 percent of psychiatrists were over age 65, and 33.2 percent of orthopedic surgeons. 

Given these predictions, it is discouraging that among specialties, there is a looming shortage of geriatricians (doctors who care for diseases in the elderly). The American Geriatrics Society estimates a need for as many as 30,000 geriatricians by 2030 to meet demand—more than four times the approximately 7,000 practicing today. This shortage exists in both rural and urban areas, and the states of Florida, California, Texas, New York, and Pennsylvania will be the most in need of geriatricians.  

Part of the shortage is driven by burnout. If a doctor is too tired to keep working, does not feel that the workplace has enough support, or otherwise no longer feels that the tradeoffs of the job are worth it, a doctor has free will just like anybody else and can quit when the work is too much.

Part of the shortage is policy-driven. In the 1990s, workforce planners feared that unrestricted growth in federally funded residency training would produce a physician surplus and argued that training should be aligned with population needs. Congress responded in 1997 by capping each hospital’s Medicare-funded residency positions at roughly its number of residents in 1996, rather than updating with population growth or physician need. As the population grew and aged, demand for care increased, and physicians approached retirement, the training system did not expand at the same pace and the assumptions behind the policy no longer matched conditions. The U.S. population has grown by 30 percent since then, with an increase of approximately 70 million people. Congress meanwhile has made only limited, incremental increases: the 2021 and 2023 appropriations acts authorized a combined 1,200 additional Medicare-supported residency positions, phased in over several years.

Medicare is the largest source of Graduate Medical Education (GME) funding. Its direct and indirect payments vary by hospital and Medicare does not pay a uniform amount per resident; in 2023, Medicare paid approximately $22 billion to support GME at more than 1,400 hospitals. Hospitals can and do train residents above their Medicare caps using other sources of support. In 2018, 70 percent of teaching hospitals trained at least one resident above these caps, although Medicare still funded the large majority. The cap is therefore not a legal ceiling on total residency training; it is a financial constraint that makes expansion more costly and uneven. Residency training is capital-intensive. Teaching hospitals incur costs of approximately $150,000 per resident per year, covering resident salaries, faculty supervision time, and other costs.

Medical school enrollment has grown, but residency capacity has not expanded proportionately. The next section explains how one specific rule—the requirement that most foreign-trained doctors repeat U.S. residency—turns this constrained pathway into an American shortage.

The Residency Bottleneck: A Self-imposed Handicap

To understand how the redundant residency requirement affects the doctor shortage, you have to understand residency. In medicine, graduating from medical school is only the first half of the process. To practice independently and legally, a doctor must complete a residency–the years of hands-on training in hospitals and clinics under supervision, usually three years for family medicine and up to seven years or more for surgical specialties.

The duration of this requirement varies substantially by state. In a 2023 summary of traditional state licensure rules, the American Medical Association reported that every state licensing jurisdiction required IMGs to complete at least one year of accredited U.S. or Canadian graduate medical education; 12 jurisdictions required two years, and 25 required three years. These figures describe the traditional pathway. 

Since 2023, however, a growing number of states have enacted alternative pathways that allow some qualifying applicants to avoid some or all of the traditional GME requirement by demonstrating foreign training, recent practice, examination results, supervised practice, and clinical competence. As of June 2026, the FSMB lists 24 states with enacted legislation authorizing such pathways, although the requirements vary and the traditional rules still apply to many applicants.

These are typically the most grueling years of a doctor’s career. Residents are a central part of the workforce at teaching hospitals, and often work up to the limit set by the Accreditation Council for Graduate Medical Education (ACGME). This involves 80-hour workweeks and shifts that can last up to 24 consecutive hours. For that workload and level of responsibility, compensation is modest; the American Medical Association reports an average first-year stipend of $68,166, increasing by a few thousand dollars each year.

For graduates of U.S. medical schools, this path is competitive but relatively clear. Those who seek residency enter a national “Match” system that pairs applicants with residency programs. In the 2025 Main Residency Match, 93.5 percent of active U.S. seniors at schools granting a Doctor of Medicine (MD) degree and 92.6 percent of active U.S. seniors at schools granting a Doctor of Osteopathic Medicine (DO) degree matched to first-year residency positions through the main process; after the supplemental placement process, those rates rose to 97.8 percent and 98.4 percent, respectively. These figures describe active applicants, not every medical-school graduate. Some graduates do not seek residency immediately or at all, while others may apply narrowly or face intense competition for particular specialties or locations. Physicians who complete residency, pass the required examinations, and satisfy state-specific licensing requirements can then enter independent practice.

These figures clarify the nature of the bottleneck: the problem is not that most U.S. graduates fail to match, but that the system has limited capacity for additional applicants—including qualified IMGs—while medical-school enrollment, population, and demand for physicians continue to grow.

For doctors trained abroad, this is a major hurdle. Even where only one year of accredited residency is required, an IMG must first obtain a position in a competitive residency system before becoming eligible for full practice. The problem is not that one additional year is unbearable. The practical problem is securing a qualifying residency position in the doctor’s preferred field of practice. These positions are limited, and many programs favor recent graduates. Some physicians trained in another specialty are encouraged to retrain in primary care, even when that means moving away from the field in which they have the most experience. Some residency programs also use time-since-graduation limits, with certain programs declining to consider applicants who completed medical school more than three to five years earlier. These limits are intended to ensure that applicants’ clinical knowledge and recent practice remain current, but a blanket cutoff can exclude experienced physicians before programs evaluate their actual competence.

This is the residency trap. The needed resource to become licensed as a doctor is in limited supply. The bottleneck for becoming a doctor is not the desire to practice medicine, or even the number of immigrant doctors admitted into the country, but the number of residency slots available every year. 

The United States does not treat all foreign postgraduate training alike. Canadian residency is often recognized alongside U.S.-accredited training, while residency completed in other countries may receive limited or no credit toward a state’s domestic GME requirement. The distinction is institutional and historical: U.S. regulators became familiar with and incorporated specific Canadian accrediting bodies into their rules over many decades. It does not mean that Canadian accreditation is necessarily superior to accreditation elsewhere, nor that every Canadian program is identical to every U.S. program.

Expanding the number of residency positions remains an important long-term response to the physician shortage. But even a substantial expansion of residency positions would take years to affect the practicing physician workforce and would not address physicians who have already completed postgraduate training abroad. State-level alternative pathways could address that existing pool more immediately.

States control physician licensure because the Constitution leaves regulation of health, safety, and professional practice to the states under their “police powers.” Courts have repeatedly treated licensing the practice of medicine as a classic state function, and every state has a medical practice act that creates a medical board to decide who can be licensed, under what conditions, and how to discipline those who fall short. 

Within that framework, state medical boards and legislatures set the core requirements for IMGs: how many years of accredited GME to demand, whether any foreign postgraduate training can count, and whether there are provisional or alternative licenses for internationally trained physicians. This is why the number of years of residency required varies among different states. 

Federal law still shapes the background by capping Medicare funding for residency slots and governing immigration visas, but it does not dictate whether a state treats foreign graduate medical training as a valid substitute for North American training.

In fact, “North American” training was not always the norm. Canada was not always included. States have gradually come to treat Canadian residency as functionally equivalent to U.S. training, but the shift has been piecemeal and state‑by‑state rather than tied to a single decision. Well into the late 1990s, at least a dozen states still did not accept residency accredited in Canada for licensure purposes. Over the following decades, many legislatures and medical boards made amendments to add explicit references to residency approved by the Royal College of Physicians and Surgeons of Canada or the College of Family Physicians of Canada. By 2025, most jurisdictions count Canadian GME alongside ACGME training when they specify “U.S.‑ or Canada‑based” residency requirements for IMGs, while postgraduate training completed in most other countries remains largely disregarded.

The history of Canada’s gradual inclusion underscores how arbitrary these rules can be. What counts as “acceptable” foreign training has shifted not because of new evidence about quality or patient outcomes in Canada, but because states eventually grew comfortable with the idea. The same logic could support more flexible pathways for other countries as well.

The contingent nature of these lines becomes even clearer when looking the other direction. Various provinces in Canada did not always accept U.S. training and have been expanding their alternative licensure pathways for qualifying U.S.-trained physicians in response to a recent influx of interest. Canada has no single national rule for U.S.-trained physicians. Licensure is determined by provincial regulators, and requirements vary from traditional Canadian certification and assessment to newer pathways recognizing specified U.S. residency training and American board certification. Since 2023, several provinces—including Nova Scotia, Ontario, Manitoba, Alberta, and British Columbia—have reduced or removed additional Canadian training, examination, supervision, or certification requirements for defined categories of U.S.-trained physicians. These reforms are not identical, but they reflect a broader shift toward evaluating comparable training systems directly rather than treating the traditional Canadian pathway as the only route to practice.

Until a bylaw change in 2025, British Columbia did not treat U.S. training alone as sufficient for full licensure: U.S.-trained, ABMS-board-certified physicians could generally practice only through “USA certified” or provisional classes, while the full family and specialty licence classes remained tied to Canadian certification. Only with the July 7, 2025 amendments did the College of Physicians and Surgeons of British Columbia decide that accredited U.S. residencies and American board certification were enough for direct eligibility for full licensure. In explaining the change, the College of Physicians and Surgeons cited the need to reduce barriers to licensure and the absence of evidence that U.S.-trained and certified physicians posed greater patient-safety risks than their Canadian-trained and certified counterparts.

That example is revealing because the United States often treats its own training as the global benchmark. Yet even a neighboring Canadian province long declined to treat it as automatically equivalent for full practice rights. What counts as the “gold standard,” in other words, is not a self-evident fact about quality but a regulatory judgment that can change over time to recognize other high-quality training systems.

What We Know About IMG Safety

If these rules are contingent and changeable, the obvious question is why they look the way they do today. These requirements may serve legitimate safety purposes, but the relevant question is whether requiring every international medical graduate to repeat U.S. or Canadian residency specifically adds enough safety beyond existing credentialing, examinations, and supervised training to justify the cost and delay.

Multiple large studies have found that IMGs perform at least as well as their U.S.‑trained counterparts. For example, a national cohort study of over 1.2 million patients and 44,000 physicians found that patients treated by foreign‑trained internists had equal or slightly lower 30‑day mortality compared with those treated by U.S.‑educated physicians. Other research on family medicine performance such as a multisite evaluation of resident progression shows that IMGs achieve comparable competency milestones to domestic graduates in accredited programs.

Before an IMG can enter the standard U.S. licensing pathway, the Educational Commission for Foreign Medical Graduates (ECFMG) checks whether the physician graduated from a medical school that meets its eligibility requirements. Those requirements go beyond recognition by the school’s home country: the school must meet applicable accreditation requirements, award a degree that qualifies graduates for medical licensure in that country, provide at least four years of medical education, and maintain procedures for verifying student credentials. Schools that satisfy these requirements receive an ECFMG Sponsor Note in the World Directory for specified graduation years; students and graduates of schools without a Sponsor Note are not eligible to apply for ECFMG certification. ECFMG then verifies the individual physician’s diploma directly with the issuing school. The Sponsor Note establishes eligibility to pursue ECFMG certification; it does not mean that all foreign medical education is identical to U.S. training or that every graduate is qualified for every role.

After that, IMGs need to pass the same medical exams that U.S. medical students take: the U.S. Medical Licensing Examination (USMLE) Step 1 and Step 2 CK. Step 3 is the final examination in the USMLE sequence and is generally taken during residency as part of the process of obtaining an unrestricted medical license. It tests whether a physician can apply medical knowledge and clinical judgment to evaluate patients, make diagnoses, choose appropriate treatment, and respond to changing clinical circumstances. These tests measure whether a doctor understands biomedical science and possesses the clinical skills needed for safe care with patients.

ECFMG reviews the doctor’s credentials and exam results to make sure they meet U.S. standards. Once an IMG earns ECFMG certification, they can apply to residency programs in the United States, just like graduates of American medical schools.

The candidate must secure a position in an ACGME‑ or Canadian‑accredited residency program, often within time‑since‑graduation windows that apply to all applicants, and effectively exclude many experienced foreign physicians. Only after they have completed the required one, two, or three years of residency in the United States or Canada can they satisfy the statutory or regulatory GME requirement for full licensure. 

The purpose of these safeguards is to prevent physicians without adequate medical education or clinical preparation from practicing independently, regardless of where they trained. 

The United States did not always have the credentialing infrastructure it has today. The 1910 Flexner Report documented wide variation in admissions requirements, curricula, facilities, and graduation standards among the 155 medical schools then operating in the United States and Canada. In the decades after the Flexner report, reforms led to more than half of all American medical schools closing, and medical education became much more standardized and demanding.

In today’s context, the relevant question is not whether the United States should tolerate untrained doctors—it should not. The country has spent more than a century building institutions designed to distinguish inadequate preparation from legitimate medical education. Those institutions can and do distinguish a diploma mill from a serious program that meets defined educational and clinical safety standards serving the citizens of other countries. At a minimum, medical schools must be recognized by the relevant authorities in their home countries; schools without that recognition do not qualify for ECFMG certification, and recognized schools must still meet additional ECFMG requirements. Many schools do not qualify. 

The question, then, is not whether foreign training deserves scrutiny, but whether physicians who have cleared school review, credential verification, examinations, and clinical assessment should nevertheless be presumed unqualified until the final step of repeating an entire U.S. residency. The relevant divide is between inadequate and qualifying preparation, not simply between American and foreign training.

The internal U.S. residency system itself illustrates this distinction. ACGME accreditation establishes common baseline requirements, but programs do not provide identical training experiences.

There is actually high variance among U.S. residency programs. For example, the Cicero Institute compared pediatrics in Washington and Texas: 

While the ACGME requires a minimum of two community outpatient blocks during pediatrics residency, Seattle Children’s has three blocks, while UTSA allocates five blocks for their trainees.¹⁴ Additionally, two of the three blocks for Seattle Children’s are community practices in Washington, Wyoming, Alaska, Montana, and Idaho. It is clear that a pediatrician trained at one institution will not have an identical experience base to pediatricians from other institutions nationwide. And yet a physician trained in pediatrics at UTSA can obtain a license in Washington state or any other state in the United States despite these variations.

Just as there is variance among American programs, there is variance in programs in other countries. Nonetheless, many actually look remarkably similar to their U.S. counterparts. For example, one analysis found that the outlined skills standards for family medicine and pediatric care in India and the U.K. match very closely to those in the U.S.  

Patient safety around this topic has two dimensions: protecting patients from inadequate care and ensuring that patients can obtain timely care from physicians who meet appropriate standards. IMGs are already an important part of the workforce that provides that care, particularly in primary care and medically underserved communities.

National data from the CDC’s National Center for Health Statistics show that IMGs are more likely than U.S. medical graduates to practice in primary-care specialties and to work in primary-care shortage areas outside metropolitan statistical areas. Their patients are also more likely to rely on Medicaid or SCHIP and to live in lower-income neighborhoods. More recent nationwide research published in JAMA finds that IMGs continue to play a slightly greater role in medically underserved areas, particularly urban ones, although U.S.-trained physicians remain more represented in rural counties. Together, these findings show that IMGs are already an important source of care in primary-care shortage areas and medically underserved communities.

A sound licensure system can protect patients by evaluating each physician’s education, credentials, examinations, clinical competence, and recent experience; using supervised practice and performance review where appropriate; and denying licensure to applicants who do not meet the standard. Alternative pathways therefore need not weaken patient safety. 

Emerging Solutions and Roadmap for Reform

States should create an additional licensure pathway for internationally trained physicians who can demonstrate qualifying medical education, postgraduate training or equivalent clinical experience, current competence, and good professional standing. The pathway should supplement—not replace—the ordinary residency pathway and could initially prioritize primary care serving rural, low-income, and medically underserved communities.

This approach is already being implemented by a number of states. The Federation of State Medical Boards’ June 2026 report identifies 24 states with enacted legislation authorizing qualifying internationally trained physicians to pursue full licensure without completing a new U.S. or Canadian postgraduate training program. It also identifies 17 states that have recently considered similar legislation. 

These laws are not uniform, and some remain new or require further implementation. The trend is nevertheless clear: States are beginning to replace categorical repeat-training requirements with conditional, competency-based pathways.

Tennessee enacted an early version of its pathway in 2023, and other states followed with different models in 2024, 2025, and 2026. Tennessee’s law allows a qualified internationally trained physician to receive a provisional license after meeting specified training, practice, documentation, and competency requirements and obtaining an offer of employment from a Tennessee health-care provider with an accredited residency program. The physician must practice at that type of facility during the provisional period, and the board may revoke the license for violations of medical-safety, competency, or conduct standards. A provisional licensee in good standing becomes eligible for a full and unrestricted license after two years. 

Other states have adopted more explicitly staged systems. Illinois created a limited IMG license for applicants who satisfy requirements including ECFMG certification, USMLE Steps 1–3, an unencumbered foreign license, and either qualifying foreign postgraduate training or recent practice abroad. After two years of supervised work, the physician may receive a restricted license to practice independently in a Health Professional Shortage Area, Medically Underserved Area, or other designated underserved setting. After an additional period of qualifying practice, the physician may apply for a full unrestricted license. 

Minnesota has adopted another targeted model. Its 2025 statute authorizes a 24-month limited license for an internationally trained physician who has practiced for at least 60 months during the previous 12 years, holds ECFMG certification, has passed the required examinations, and accepts a position in a collaborative hospital or clinical setting in a designated rural area or underserved urban community. After successful practice under the limited license, completion of required continuing education, passage of Step 3, and a favorable evaluation, the physician may receive a full license. The pathway became effective January 1, 2026. 

These examples demonstrate the basic policy options and precedents. A state can link provisional practice to an approved employer, require supervision and evaluation, limit the initial license to a shortage area, or make full licensure contingent on continued good standing. Arkansas, North Carolina, and other states have adopted related models with different combinations of foreign licensure, recent practice, examinations, employer restrictions, rural or underserved-area requirements, and board review.

A model pathway for states should contain several common elements:

First, applicants should establish that their medical school is eligible for ECFMG certification and that their diploma and other credentials have been verified from primary sources. They should meet applicable ECFMG requirements, pass the required USMLE examinations, demonstrate English proficiency, and undergo criminal-background and disciplinary-history checks. Applicants should also provide evidence of formal postgraduate training, an active or recent foreign license, and a defined period of recent clinical practice. The precise requirements can vary by specialty, but they should be clear enough that applicants, employers, and medical boards know what qualifies.

Second, states should evaluate foreign postgraduate training without assuming that every international program is equivalent to a U.S. residency. The FSMB’s guidance on additional licensing pathways recognizes that international postgraduate training varies in structure, clinical exposure, and quality. It recommends formal postgraduate training as an important eligibility criterion while also identifying other relevant evidence, including curriculum review, clinical experience, specialty certification, examination results, and recent practice. Where training alone does not establish readiness, the board should require a structured clinical assessment rather than treating the applicant’s country of training as a conclusive proxy for competence.

Third, applicants should begin with a provisional or limited license tied to an approved employer and a defined scope of practice. Physicians should initially work under the supervision or collaboration of an experienced U.S.-licensed physician in a team-based setting, with access to consultation and referral. States could direct these pathways toward primary care, community health centers, hospitals, and other facilities serving Health Professional Shortage Areas, Medicaid patients, or underserved urban and rural communities. The pathway should be responsive to local need without assuming that every internationally trained physician will independently choose a rural practice location.

Fourth, states should establish a clear route from provisional to full licensure. Conversion should depend on successful completion of the supervised practice period, satisfactory performance evaluations, passage of any remaining examinations, continuing education, and the absence of unresolved disciplinary concerns. Employers should maintain appropriate malpractice coverage and report serious complaints, changes in employment, or material concerns about performance to the board. The board should retain authority to restrict, suspend, or revoke a license when a physician fails to meet safety or competency standards.

The pathway should not create a permanent second-class license. Once a physician has completed the required evaluation and demonstrated competence, the physician should be eligible for the same unrestricted license and disciplinary oversight that apply to other physicians. The objective is to change which evidence satisfies the state’s training requirement—not to reduce accountability or create a separate class of practitioners.

State legislatures and medical boards have different responsibilities. Where existing law makes U.S. or Canadian postgraduate training a condition of licensure, the legislature must authorize an alternative. The medical board can then implement the pathway through rules governing credential review, examinations, supervision, performance evaluation, renewal, and discipline. Legislatures should give boards sufficient authority and resources to review foreign training carefully, while requiring transparent standards so that terms such as “substantially similar” do not become vague or inconsistent barriers.

States should also collect data from the outset of each reform’s implementation. Early evidence is promising but narrow: A review of seven states reported that 73 percent of physicians licensed through Washington’s temporary pathway worked in underserved areas, primarily in high-need specialties such as family medicine. But the same review found that most states lacked systems to track how many physicians were licensed through different pathways, where they practiced, or their community impact. Boards should therefore report the number of applicants, approvals, denials, practice locations, specialties, complaints, disciplinary actions, retention, transitions to full licensure, and, where feasible, patient access and outcomes. The Federation of State Medical Boards recommends collecting and sharing data to evaluate pathway effectiveness.

The policy objective is straightforward: preserve the safety function of licensure while removing an unnecessary categorical barrier. States should require evidence of education, examinations, recent competence, supervision, and professional accountability. They should not require every internationally trained physician to complete additional U.S. or Canadian postgraduate training when a more targeted evaluation can determine whether that individual is prepared to serve patients safely. This would expand the effective physician workforce on a shorter timeline than training new physicians from the beginning, while directing new capacity toward communities where low-income and underserved patients face the greatest barriers to care.

Federal policy should address the longer-term side of the physician pipeline. Congress should expand Medicare-supported residency positions and establish a durable mechanism for adding positions in line with population growth, physician retirements, and projected demand. Expanding graduate medical education would increase the supply of newly trained physicians over time, but it would not by itself enable experienced internationally trained physicians to practice; that near-term problem requires the state licensure reforms described above.

Conclusion

The United States has built a health‑care system that can perform medical miracles while regularly failing at the simple task of making sure patients can see a doctor when they need one. That failure is not just a by‑product of aging demographics or bad luck. It is also the result of policy choices that constrict training pipelines and ignore the expertise of thousands of physicians who have already proven they can practice safely at a high level, largely because their training took place outside the United States and Canada. The residency trap is one of the clearest examples: a rule meant to guarantee quality has, over time, become a barrier that keeps qualified clinicians out and patients waiting.​

Reforming that rule will not fix every weakness in American health care, but it is a concrete, tractable step that lies squarely within the power of each state. Legislatures and medical boards already decide how much U.S. residency to require, whether to recognize foreign training, and whether to offer alternative pathways to licensure. 

They can, if they choose, update those rules to reflect what the evidence shows: that many internationally trained physicians meet or exceed U.S. standards and are already essential to staffing clinics and hospitals in communities that would otherwise go without care.​

The doctor shortage is not an abstract number problem. Some patients get treated in time; others stay sick—and get sicker—while they wait for care. When access to doctors depends on income and geography, opportunity does too: Lower-income and rural Americans are more likely to remain sick, less able to take on demanding work, and less free to build the lives they want. Bringing qualified internationally trained physicians into practice could give these patients more meaningful choice, shorter waits, stronger continuity of primary care, and fewer manageable conditions escalating into emergencies or costly hospitalizations. Keeping qualified physicians out of practice while patients wait is not a neutral safety precaution that has no costs; it is a policy choice to preserve scarcity, and the people with the fewest alternatives pay the highest price.

A country that prides itself on medical innovation should not accept a status quo in which doctors work other jobs outside of medicine while nearby hospitals close services for lack of staff. It should not accept multi‑month wait times and preventable complications as inevitable. The options to do better are available now. For risk‑averse states, the most cautious way to start is by placing experienced international graduates (who already staff many primary care and other basic, first‑contact roles) into team‑based primary care jobs working alongside other physicians. By lifting the residency trap and aligning licensure with reality, states can turn the ongoing doctor shortage from an intractable crisis into a solvable problem. The limiting factor is our willingness to use the talent that is already here.