Should Foreign-Trained Physicians Be Allowed to Practice Without a U.S. Residency?

The United States healthcare system is grappling with a serious physician shortage. The Association of American Medical Colleges (AAMC) projects a shortfall of up to 124,000 physicians by 2034. At the same time, thousands of foreign medical graduates (FMGs), many with years of clinical experience, find themselves unable to practice medicine in the U.S. due to limited residency opportunities.

This raises an important and increasingly urgent question: Should foreign-trained physicians be granted a path to independent practice without completing a U.S. residency?

The Current System and the Bottleneck

For FMGs, the pathway to practice in the U.S. involves passing licensing exams, obtaining certification from the Educational Commission for Foreign Medical Graduates (ECFMG), and the biggest hurdle securing a residency position. But the final and most formidable hurdle is securing a U.S. residency. Each year, there are far fewer residency slots than applicants, leaving thousands of capable physicians without a pathway to contribute, despite severe shortages in rural areas and underserved communities. This bottleneck leaves many skilled physicians unable to contribute, despite the growing healthcare needs of the U.S. population.

Arguments in Favor of Allowing Independent Practice

Addressing the physician shortage: FMGs could help fill gaps in primary care, rural healthcare, and underserved communities. FMGs represent a large, underutilized talent pool. Many have completed residency and practiced independently in their home countries. Unlocking their potential could help alleviate the healthcare gap, especially in communities where patients wait weeks or months to see a doctor.

Prior experience: Many FMGs have completed residencies and practiced independently in their home countries, sometimes for years.

Global precedent: Countries like Australia and Canada have alternative assessment pathways for internationally trained doctors, allowing them to practice under supervision or limited licenses before full integration. These models demonstrate that with the right safeguards, patient safety can be maintained while expanding healthcare capacity.

Economic benefits: Every year, the U.S. invests in international graduates through ECFMG certification and exams, but many never make it past the residency wall. Creating alternative routes to practice would allow healthcare systems to recoup that investment and serve growing patient demand. Reducing reliance on temporary solutions like locum tenens physicians and expanding access to care could lower healthcare costs in the long run.

Arguments Against

Quality and safety concerns: Without a standardized U.S.-based residency, critics argue that patient safety and clinical standards may be compromised. Ensuring patient safety remains paramount.

Differences in training: Medical training structures and healthcare systems vary globally, raising concerns about compatibility with U.S. medical practice and alternative pathways that would need robust, standardized evaluations.

Potential for inequality: Creating a separate track for FMGs could result in a two-tier system, where some physicians are perceived as less qualified and could undermine public trust.

Potential Middle Ground Solutions

Competency-based evaluations: Before receiving a limited license, FMGs could undergo standardized clinical exams tailored to U.S. healthcare systems. Allow FMGs to demonstrate clinical competence through standardized assessments.

Supervised practice periods: A set timeframe where foreign-trained physicians work under supervision in rural or underserved areas. Similar to Canada’s "practice-ready assessment" model, FMGs could work under supervision for a defined period before receiving full licensure.

Targeted licensure for underserved areas: Grant limited licenses for FMGs to practice in regions with severe physician shortages. Physicians could receive practice rights in designated areas where the need is greatest, with periodic evaluations for full licensure.

Conclusion

The wall that foreign-trained physicians face isn’t one of skill or dedication — it’s structural. The question of whether foreign-trained physicians should be allowed to practice without a U.S. residency is complex and multi-faceted. While patient safety and high clinical standards must remain priorities, the realities of the U.S. physician shortage demand innovative solutions.

By learning from other countries and creating thoughtful, competency-based pathways, the U.S. could lessen the healthcare gap, just as many states are doing with changes to the physician-PA model of practice.

REFERENCES

1. Association of American Medical Colleges. (2021). The Complexities of Physician Supply and Demand: Projections From 2019 to 2034. AAMC Report

2. Educational Commission for Foreign Medical Graduates (ECFMG). Certification Process for International Medical Graduates.  Link https://www.ecfmg.org/

3. Canada’s Practice-Ready Assessment Programs. Link https://mcc.ca/

4. The Medical Board of Australia. Competent Authority Pathway. Link https://www.medicalboard.gov.au/