Pathways for IMGs to Practice in the US without Prior Residency Training

For international medical graduates (IMGs), securing a spot in U.S. medical residency is often a significant hurdle in their journey to practicing medicine in the United States. The traditional pathway to practicing medicine in the US mainly requires passing the United States Medical Licensing Examination (USMLE) exams, obtaining Educational Commission for Foreign Medical Graduates (ECFMG) certification, and completing a U.S. residency program. This process can take years as the match process is very extensive and competitive, and residency training can take anywhere from three to five years. However, some states offer alternative routes that allow IMGs with experience and previous residency training in their home countries to practice without having to complete U.S. residency training. These opportunities are limited and have their own requirements but can be valuable for experienced IMGs looking for a more straightforward entry point into the U.S. healthcare system.

Pathways for IMGs Without prior US Residency Training

Numerous states have already passed this type of legislation for IMGs to practice without residency training. The states that have passed them are Florida, Idaho, Illinois, Iowa, Louisiana, Massachusetts, Tennessee, Virginia, and Wisconsin. After fulfilling all requirements, these states provide a full unrestricted license for IMGs who fit certain criteria. Many of these states start by offering a provisional or temporary license that requires working in the specific state for a set time period before applying to receive a full license.

Additionally, while there are only nine states that currently have this type of legislation in place, many other states have pending legislation to offer similar pathways. States like Arizona, Connecticut, Indiana, Maryland, Minnesota, Nevada, North Dakota, Oklahoma, Oregon, Rhode Island, Texas, Washington, and Wyoming are considering similar legislation. With more states introducing this pathway into their legislation, this could mean more opportunities for IMGs to enter the US healthcare system without having to take part in the residency match or formal US residency training.

California and New York only offer a limited license to practice medicine. California offers a Special Permit for international physicians who are not licensed in the United States or have not completed a US residency program. You must be sponsored by a medical school, hospital, or an approved fellowship training program in California. As stated by the Medical Board of California, "These permits authorize you to practice medicine only within the sponsoring medical school and any of its affiliated institutions. Depending upon the type of Special Program, there may be supervision requirements, limits on permitted activities, or eligibility limits based on U.S. citizenship."

New York offers a Limited Permit valid for two years and may be renewed for up to two additional years. To be eligible for a limited permit, those must "have satisfied all requirements for a license as a physician except those relating to examination and citizenship or permanent residence status in the U.S. -or- be an International Medical Graduate (IMG) who has met the education requirement and holds a standard certificate from ECFMG."

The specific requirements and additional conditions for current states offering opportunities for pathways without prior U.S. medical residency training are as follows:

State	Licensure Type	Requirements	Additional Conditions
Florida	Unrestricted License	Have an active license in their home country Have practiced medicine for the 4 years Completed a residency program in their country Be ECFMG certified Have an offer for full-time employment as a physician from a health care provider that operates in Florida	Maintain employment with the original employer or with another health care provider Working at a location in Florida for at least 2 consecutive years after licensure
Idaho	3-Year Provisional License	Submit a completed written application to the board  Have an offer for employment as a physician at any sponsoring entity that operates in the state of Idaho Report any past or pending disciplinary issues to the board and do not have disqualifying disciplinary issues as determined by the board Passing score on USMLE Step 1 and Step 2 exams. Have a fingerprint-based criminal history check must be eligible to obtain federal immigration status that allows the international physician to practice as a physician in the United States	At the conclusion of the three (3) year period, an international physician shall be eligible to apply for a full license if: The international physician was employed and training for the full three (3) years The supervising physician provides a letter of recommendation The international physician is not the subject of an active investigation by the board and The international physician has passed the USMLE 3 or equivalent exam as approved by the board.
Illinois	2-Year Limited License	Have completed residency training in home country Be ECFMG Certified Passed USMLE Step 1, Step 2, and Step 3 Maintain an unencumbered license from their home country Submit a fully completed application form Provides an official transcript and diploma or official transcript and certification of graduation and proof of Educational Commission for Foreign Medical Graduates (ECFMG) certification Submit evidence of active practice of medicine in home country in at least 3 of the last 10 years. Must show evidence of USCE if active practice predates 3 years. Have an agreement with a sponsoring entity that provides an assessment and evaluation program designed to develop, assess, and evaluate the physician's nonclinical and clinical skills and standards for medical practice. Submit a background check	Upon the issuance of the limited license, an individual may only practice: 1) Within an approved sponsoring entity which must be either a hospital, a critical access teaching hospital, a Federally Qualified Health Center, a State facility, a community health center, or another facility approved by the Division; and 2) Under the supervision and control of an approved sponsoring entity who designates a faculty supervisor who possesses a full and unrestricted physician license that has never been disciplined in the State of Illinois. May be renewed an unlimited number of times for periods not to exceed 2 years each.
Iowa	3-Year Provisional License	Have a medical doctorate issued by an international medical program and be in good standing Have been in good standing with the medical licensing or home country's regulatory institution during the immediately preceding five years and has no pending discipline Have completed a residency program or similar post graduate medical training Have practiced medicine as a licensed physician for five years following the completion of a residency Have basic fluency in the English language Receive a passing score on USMLE examination Pass a background check Complete a licensure application and pay all required fees Have been evaluated by the educational commission on foreign medical graduates Possess a federal immigration status	Full licensure will be granted after 3 years as long as: The license hasn't been revoked or surrendered by the licensee Be employed by a health care facility in this state during the entirety of the provisional licensing period
Louisiana	2-Year Temporary Permit	Has been granted a medical doctorate or substantially similar degree by an international medical program of good standing Is in good standing with the medical licensing or regulatory institution of the individual's licensing country. Has completed a residency or substantially similar post-graduate medical training in the individual's licensing country or practiced as a medical professional performing the duties of a physician in the individual's licensing country for no less than five years. Is a citizen of the United States or Canada or legally entitled to live or work in the United States and possesses basic fluency in the English language Has submitted sufficient evidence to the board that the applicant has an offer for employment as a physician at a facility owned or operated by a hospital licensed in Louisiana	A full, unrestricted license will be granted given the pursuant is in good standing two years after the date of the issuance of the temporary permit. A holder of a temporary permit who obtains a full and unrestricted license is not subject to the limitation of practicing at a licensed hospital. The board may revoke a temporary permit based upon a finding that clear and convincing evidence exists that a temporary permit holder's medical services violated medical safety, competency, or conduct standards established by the board Can only provide medical services at a facility owned or operated by a hospital licensed by Louisiana
Massachusetts	2-Year Limited & Restricted License	The first step in the alternative pathway is a limited license. For eligibility, the physician must: Have an M.D. or equivalent degree from a legally chartered medical school outside the United States recognized by the World Health Organization Have at least one year of the practice of medicine in another country pursuant to a license or other authorization to practice Have a valid certificate issued by the  Educational Commission for Foreign Medical Graduates Have proof of a passing score on Step 1 and Step 2-Clinical Knowledge of the United States Medical Licensing Examination Have an agreement with a  participating health care facility to participate in assessment and to work full time after the limited license is issued	Second step in the alternative pathway is a restricted license which allows the physician to practice independently for two years in a designated “physician shortage area” in primary care, psychiatry, or other specialty approved by BORIM.  The restricted license is renewable for one additional two-year period. Third step in the alternative pathway after practicing for at least two years under a restricted license and providing proof of a passing score on Step 3 of the United States Medical Licensing Examination is applying for a full, unrestricted license
Tennessee	2-Year Provisional Licensure	A certificate from a medical school whose curriculum is judged to be acceptable by the board A copy of a permanent Educational Commission for Foreign medical Graduates (ECFMG) certificate A nonrefundable application fee as set by the board and by an examination fee Sufficient evidence of good moral character Evidence of being a citizen of the United States or Canada, or legally entitled to live or work in the United States; and Evidence of satisfactory completion of a three-year post-graduate training program approved by the American Medical Association or its extant accreditation program for medical education, or its successor. Such a person may apply to the board for licensure or testing in accordance with the present law within 12 months of completion of the post-graduate training program if satisfactory performance in such program is demonstrated to the satisfaction of the board	The board must also grant a full and unrestricted license to practice medicine to a provisional licensee who is in good standing two years after the date of initial licensure
Virginia	2-Year Restricted License	Has received a degree of doctor of medicine or its equivalent from a legally chartered medical school outside of the United States recognized by the World Health Organization Has been licensed or otherwise authorized to practice medicine in a country other than the United States, and has practiced medicine for at least five years Has a valid certificate issued by the Educational Commission for Foreign Medical Graduates or other credential evaluation service approved by the Board Has achieved a passing score on both USMLE Step 1 and Step 2 CK Has entered into an agreement with a medical care facility that provides an assessment and evaluation program designed to develop, assess, and evaluate the physician's nonclinical skills and familiarity with standards appropriate for medical practice in the Commonwealth according to criteria developed or approved by the Board Will enter a full-time employment relationship with such medical care facility after the Board issues a license pursuant to this subsection Has satisfied any other criteria that the Board may require for issuance of a provisional license pursuant	An individual who successfully obtains a license and practices under such license until its expiration shall be eligible to apply for a renewable two-year restricted license to practice medicine in a medically underserved area in Virginia or a health professional shortage area The Board may issue such renewable license to an applicant if the applicant submits evidence acceptable to the Board that the applicant: Has successfully completed the participating medical care facility's assessment and evaluation program Has achieved a passing score on USMLE Step 3 Will enter a full-time employment relationship with a medical care facility. After at least two years of practice under a renewable two-year restricted license, an internationally trained physician shall be eligible to apply for a full, unrestricted license to practice medicine.
Wisconsin	3-Year Provisional License	Has an offer for full-time employment as a physician in Wisconsin from a federally qualified health center, a community health center, a hospital, an ambulatory surgical center, or any other health care facility approved by the board. Has been granted a medical doctorate or a substantially similar degree by an international medical program. Has completed a residency program or a postgraduate medical training program that is substantially similar to a residency program. Has practiced as a fully licensed or otherwise authorized physician in his or her country of practice for at least five years after completing a residency program or a postgraduate medical training program that is substantially similar to a residency program. Has practiced continuously as a physician in his or her country of practice for at least one out of the five years immediately preceding the date that the applicant submits an application for a provisional license. Has been in good standing with the medical licensing or regulatory agency in their home country for the five years preceding application & does not have any pending disciplinary action Has obtained certification by the ECFMG or another evaluation entity approved by the board. Has passed all steps of the USMLE Has, or will have prior to working as a physician in Wisconsin, a federal immigration status and employment authorization Possess basic fluency in the English language.	Every six months or upon request of the board, the holder of a provisional license must submit to the board a statement certifying whether the license holder is still employed as a physician in Wisconsin and whether the license holder has been subjected to professional discipline as a result of the license holder’s practice. If the license holder has been subject to professional discipline, the license holder must submit to the board a description of the circumstances of the discipline. The board may suspend or revoke a provisional license if a majority of the board determines that the holder of the license is no longer employed as a physician in Wisconsin by an employer described in the act. The holder of the license must be granted an opportunity to be heard prior to the board’s determination. A provisional license converts into a license to practice medicine and surgery after practicing medicine full-time in Wisconsin and maintaining good standing for three consecutive years.

Conclusion

With more states introducing this type of legislation, these pathways could be promising for international medical graduates pursuing medical careers in the U.S. and addressing the U.S.'s ongoing physician shortage. While many of these programs offer full licensure without prior U.S. residency training, there are additional requirements that can require years of temporary or provisional licensure as well as other requirements. It's important to understand each state's requirements and additional conditions, and better understand if they meet your background and future goals.

Additionally, it is highly recommended to read the full details of these laws and regulations by visiting the state's or state medical board's page for more information. We have provided links and resources used to provide this data below.

We hope that this blog has been information and helpful for you. Wishing you all the best in your journey in medicine and beyond!

---

Links & Resources:

California - https://www.mbc.ca.gov/Licensing/Physicians-and-Surgeons/Apply/Special-Permits/

Florida - https://flboardofmedicine.gov/licensing/medical-doctor-unrestricted/

Idaho - https://legislature.idaho.gov/statutesrules/idstat/title54/t54ch18/sect54-1812/

Illinois - https://s3.amazonaws.com/govhawk-registers/IL_20250110.pdf

Iowa - https://www.legis.iowa.gov/docs/ico/chapter/148J.pdf

Louisiana - https://www.legis.la.gov/Legis/ViewDocument.aspx?d=1367899

Massachusetts - https://www.mass.gov/info-details/board-statement-on-recent-law-regarding-new-licensing-pathway

New York - https://regs.health.ny.gov/sites/default/files/proposed-regulations/Hospital%20Medical%20Staff%20-%20Limited%20Permit%20Holders.pdf

https://www.op.nysed.gov/professions/physicians/license-requirements#limited-permits

Tennessee - https://wapp.capitol.tn.gov/apps/Billinfo/default.aspx?BillNumber=SB1451&ga=113

Virginia - https://law.lis.virginia.gov/vacode/title54.1/chapter29/section54.1-2933.1/

Wisconsin - https://docs.legis.wisconsin.gov/2023/related/lcactmemo/act214.pdf