International Medical Graduates in America: Navigating a Winding History of Immigration Laws and Licensure Requirements

State legislative initiatives that were started in 2023 to streamline the licensing of internationally trained physicians (ITPs) have garnered bipartisan interest and support across the country. The new approach, more broadly applicable than previous efforts, precludes a requirement for Accreditation Council for Graduate Medical Education-accredited graduate medical education conducted in the United States. The change is the most recent development in our nation's long and winding history of licensing international medical graduates (IMGs). At the turn of the 20th century, only about 100 IMGs presented to state medical boards each year for licensure. Medical graduates around the world who sought quality postgraduate training opportunities, including those from the United States, looked to Europe. Nativist sentiment and state and federal laws in the 1920s discouraged or prohibited immigration for many internationally educated or trained physicians. That changed substantially during and after World War II when a population surge, an increase in physician refugees, and, later in the 1960s, relaxed immigration laws combined with a robust expansion of hospitals to shift the medical regulatory landscape. The result was greater receptivity to IMGs, with concerns about prevailing credentialing models predicated on recognition by state medical boards of "approved" international medical schools. The establishment of the Educational Commission for Foreign Medical Graduates in the 1950s mirrored a broader shift toward evaluation of persons and their capabilities. Recent demographic pressures (for example, a growing and aging patient population and a maldistributed and insufficient physician workforce) are prompting a flurry of state legislative initiatives to improve access to care and welcome more IMGs, especially ITPs, in a trend that runs counter to growing federal restrictions on immigrants and international workers.