Now Doctors Can Come to the USA to Practice Medicine Without the Need of Medical Residency

Now, ECFMG-certified doctors can practice in the USA without the need for repeat medical residency training. This month, in September 2025, Texas has become the newest state to open an alternative pathway for international medical graduates (IMGs) to get a license to practice medicine in Texas without the requirement of medical residency training in the USA.

If a foreign medical graduate (FMG) also called an international medical graduate (IMG) is ECFMG-certified and has five years of clinical experience, he/she can now obtain a license in Texas.

Let us talk of basics first.

Medical doctors (physicians) become eligible to practice in the USA in one of two ways:

AMG (American Medical Graduate)

This individual has obtained his or her medical degree in the USA, either as an MD student or a DO (Doctor of Osteopathy). This individual has studied for 4 years in medical or osteopathy college after 4 years of a regular college or university degree.

IMG

Out of 1.1 million actively practicing doctors in the USA, about 25% come from foreign countries. They are called international medical graduates (IMGs).

For an AMG: After getting an MD diploma, the medical graduate has to do three years of residency in an ACGME (Accreditation Council of Graduate Medical Education) approved residency program, and then he or she can start practicing. The license to practice is typically state-based, so depending upon the state, after one to three years of medical residency training, the resident doctor can obtain a full license to practice in that state.

For international medical graduates: These are doctors who studied in medical schools outside the USA. To be at par with medical graduates of the USA (AMG), they have to get licensed by ECFMG (Educational Commission for Foreign Medical Graduates)—which is a Philadelphia-based commission.

ECFMG certification is obtained after passing the USMLE steps (United States Medical Licensing Examination), which includes Step One, Step Two, and, if someone wants to come on an H-1B visa, Step Three as well. USMLE is administered by ECFMG. Thus, an ECFMG-certified IMG comes to the US to pursue residency training first, and then he/she becomes eligible to obtain the physician license to practice medicine.

There is a shortage of doctors in the USA. Texas state (2nd largest state after Alaska) alone has a current shortage of 10,000 physicians, and the US-wide shortage is expected to increase to 86,000 by 2036. That is why, in the last couple of years, many states have executed laws to enable foreign-trained physicians (FTPs) to come and practice in the USA without the need to repeat residency training in the US.

Steps under the new law: Alternative pathway for foreign-trained physicians (FTPs):

1. Must have obtained a medical degree from a foreign medical college enlisted in WHO’s directory and be licensed in that country with good standing.

2. Take USMLE Steps One, Two, and possibly Step Three, and obtain ECFMG certification.

3. Must have four to five years (this duration varies among states) of experience in clinical practice in his/her country.

4. Apply to a medical or healthcare facility in the USA states.

5. If approved, apply for a provisional license, which is for one to two years, depending on the state.

6. Work only in HPSA (Health Professional Shortage Areas) as designated by the Department of Health and Human Services for one to two years.

7. After that, obtain full licensure, which does not restrict them to practice only in rural areas—they can go anywhere.

Exclusions: Doctors from certain countries are excluded from pursuing the alternative pathway for licensure. Graduates from countries included in the annual threat assessment by the Directorate of National Intelligence such as Afghanistan, North Korea, Cuba, Iran, Syria, Russia, and China are barred from applying for the positions.

Some critics say the solution does not lie in bringing doctors from foreign countries. They argue that the lawmakers are failing to address the shortage of medical residency slots in the USA. After getting an MD diploma, medical graduates have to compete for medical residency through a program called Residency Match, which has been in effect since 1952.

In 2025, for example, the NRMP (National Residency Matching Program) offered 37,667 PGY-1 seats, while the number of applicants was 47,000. Thus, 9,500 medical graduates—including American medical graduates (MD or DO) and international medical graduates—went unmatched, i.e., they could not get into medical residency training (postgraduate training). In other words, for one student, there are only 0.82 seats for medical residency training. Advocates of medical education have been speaking out that the number of residency seats must be increased in the US.

Still, this is a welcome step, and it enables many experienced ECFMG-certified doctors to come and start practicing in the US without the need for repeat medical training.

Many states have offered this pathway. According to FSMB (Federation of State Medical Boards), 18 US states (out of 50 states) have passed legislation to allow qualifying internationally trained medical doctors to obtain medical licensure without the need for medical residency training (also called postgraduate training or PGT).

Out of the 18, sixteen US states have passed the legislation without additional strictures. They are: Illinois, Iowa, Idaho, Wisconsin, Virginia, Tennessee, Florida, Indiana, Minnesota, Nevada, Texas, Rhode Island, and North Carolina.

Two states, which are large states, New York and California, have created limited license pathways.

• New York State: They have not waived the immigration requirement. For example, the person should be either a green card holder or an American citizen.

• California: They have not waived the medical residency training requirement, so technically, they have not created an alternative pathway.

But for physicians of Mexico, they have created a pilot program called the Physicians from Mexico Pilot Program (MPP), which enables a time-limited international medical graduate license to Mexican doctors. As we know, California borders Mexico.

The writer is a board-certified neonatologist and practices in Illinois state.