Assistance Programs to Medical Licensure for IMGs Living in the US

¹PhD, Assistant Teaching Professor in Communication and Global Health Program, University of California, San Diego, United States

Date submitted: 25-Feb-2024

Email: Lillian Walkover (lwalkover@ucsd.edu)

This is an open access journal, and articles are distributed under the terms of the Creative Commons Attribution-Non Commercial-Share Alike 4.0 License, which allows others to remix, tweak, and build upon the work non-commercially, as long as appropriate credit is given and the new creations are licensed under the identical terms.

Citation: Walkover L, Bell S. Assistance Programs to Medical Licensure for IMGs Living in the US. Educ Health 2024;37:158-163.

Online access: www.educationforhealthjournal.org
DOI: 10.62694/efh.2024.25

Published by The Network: Towards Unity for Health

Background

The American Association of Medical Colleges estimates that the US experienced a shortage of 20,400 physicians in 2017, and predicts that this will grow to a shortage of up to 121,900 physicians by 2032.¹ International Medical Graduates (IMGs) make up approximately one quarter of all practicing physicians in the US² and are key to addressing shortages. IMGs tend to practice in underserved areas, and take care of more minority, Medicare, and Medicaid patients, than US medical graduates. In addition, they have the potential to provide culturally and linguistically competent care in underserved communities for increasingly diverse patient populations.³

The term “IMG” includes both US citizens (USIMGs) and non-US citizens (non-USIMGs) who graduate from medical school outside the US. To practice medicine in the US, all IMGs must obtain a US medical license, regardless of their experience before arriving. Their education must be certified by the Educational Commission on Foreign Medical Graduates (ECFMG), and they must pass the US Medical Licensing Exam (USMLE) and complete a residency program in the US before applying for a license. There are no formal regulations that require residency programs to favor US medical graduates, but graduates of US medical schools are more likely to be accepted into a residency and to match in prestigious programs.⁴

Many non-USIMGs come to the US to pursue graduate medical education (i.e., residency programs), but others enter the US for other reasons, including those forced to flee from their homelands, often after the completion of medical school and at different stages of their careers.⁵ There are more than 65,000 non-USIMGs who live in, but are not licensed to practice medicine in the US.⁶ During the past 20 years, in part driven by studies forecasting physician shortages and as part of efforts to reduce health disparities, programs have been established to support US medical licensure for non-USIMGs living in the US. The objective of this paper is to identify and assess the range and type of support currently available to this population.

Methods

A scoping review was conducted in 2018 of physician career assistance programs for non-USIMGs already in the US when they begin the US medical licensure process (see Figure 1). The first author used the keywords “physician reentry” in Google, identifying individual programs and four databases: Federation of State Medical Board’s (FSMB) Directory of Physician Assessment and Remedial Education Programs, American Medical Association’s (AMA) Observership Program Listings for International Medical Graduates, IMPRINT Program Map: Integrating Foreign-Trained Immigrants and Refugees, and The Physician Reentry into the Workforce Project. Each database was searched with the same keywords, yielding an initial list of 14 programs.

Program websites and email outreach were used to review identified programs. Inclusion criteria were: providing physician career assistance; providing services available to physicians who have never been licensed to practice medicine in the US; and having a non-profit model. For-profit programs are generally prohibitively expensive for non-USIMGs. Exclusion criteria were not providing physician career assistance; providing services only to physicians who currently or in the past have been licensed to practice medicine in the US; and having a for-profit model. Eight of 14 programs met the criteria for inclusion in the review, including one program that is an umbrella organization supporting eight regional programs, resulting in an initial list of 16 programs. The process described above was repeated in 2023, resulting in an updated list of 17 programs.

Results

Tables 1 and 2 provide an overview of 17 physician career assistance programs that provide services available to non-USIMGs living in the US. Together, these programs have helped over 5,000 physicians pursue a variety of careers, including supporting at least 276 non-USIMGs to match to medical residency programs in the US.

Table 1 Physician career assistance programs providing services to non-USIMGs

Table 2 Median knowledge assessment scores for the PEM fellows, test consisted of seven PEM board examination practice questions (pre IQR 57, post IQR 22 retention IQR 43)

The organization with the broadest geographic reach is the Welcome Back Initiative, an umbrella organization founded in 2001. The Welcome Back Initiative runs Welcome Back Centers (WBCs) in partnership with local organizations. WBCs work with a community college, regional health center, or other organization, where Educational Case Managers provide assessment, guidance, and access to education for immigrants in a variety of health professions. We identified eight WBCs that provide services to physicians in seven states (see Table 2). WBCs have served roughly 15,000 internationally trained health workers from 167 countries. Thirty-three percent of the internationally trained health workers are physicians, and 128 physicians served by WBCs have been accepted into residency programs.

Two programs provide support for clinical training through residency preparation (Table 1).

They are both called, “IMG Program,” but are not institutionally connected. The California program is hosted at UCLA and enrolls IMGs willing to commit to a Family Medicine residency program in California that serves an under-resourced community. Applicants must have finished medical school or residency in another country within the last five years, and be bilingual and bi-culturally competent in US American and Latin American cultures. Since it was launched in 2006, the UCLA program has supported more than 128 English-Spanish bilingual physicians to match to Family Medicine residencies in California. The Minnesota program seeks to relieve the state’s primary healthcare shortage. It provides career guidance, financial support, and residency preparation. In 2018 the program reported a database of 158 non-USIMGs (130/158 were actively pursuing a residency), and had supported 20 physicians who matched to a residency.⁷

Three smaller-scale programs offer educational case management and connections to English language and other courses for non-USIMGs. Whitetulip Health Foundation is an association of health professionals that provides mentoring, career guidance, workshops on healthcare topics, and scholarship programs. GT-DOCs (Global Talent Doctors) develops customized plans for individual medical professionals and peer support for USMLE preparation and licensure. The International Medical Graduates Academy was developed by a group of non-USIMGs in Washington State who have been engaged in policy advocacy, and provides mentorship and career guidance, both for members living in the state, and with an expanding national network.

Three programs broadly target clinicians interested in reentry to clinical work and provide resources that are useful to non-USIMGs living in the US. The Drexel Medicine Physician Refresher/Re-entry Program provides online clinical skills courses and clinical preceptorships. CPEP’s Reentry to Clinical Practice Programs and Texas A&M’s KSTAR (Knowledge, Skills, Training, Assessment and Research) Physician Resources provide assessment and education.

Discussion

The 17 non-profit career assistance programs identified in the review provide individualized case management or educational guidance (16/17), access to clinical experience (7/17), English courses focused on technical language skills (4/17), and financial support for the cost of certification, licensing exams, and application to residency (2/17). However, no one program provides all these services. Two-thirds (13/17) of the programs provide assistance in a limited geographical area, and are not accessible to IMGs outside the immediate catchment area. Direct, targeted services are available in at least one major city in 10 states. Local networking is available in 24 states, but in the remainder of the country, direct services for this population are not available.

The review identified seven programs that provide access to experience in US medical settings. According to American Medical Association guidelines, the completion of an observership should not be required for admission, but 90% of non-USIMGs complete US-based clinical experience before successfully matching to a residency.⁸ Observerships provide opportunities to observe medical practice in a US clinical setting, connect with a social network of insiders, and identify physician mentors to write letters of recommendation.

Previous studies show that many non-USIMGs living in the US want to return to practice but face consistent barriers.^5,9 Recommendations from the literature to support this population include streamlining the licensure process as well as educational guidance, English courses focused on technical language skills, and financial support for the cost of certification, licensing exams, and residency application.^9,10 Each of these services is provided by one or more of the programs identified by the review, but there is a need to expand the range of services provided—and the total number of programs across the country.

Additional research is needed to assess the effectiveness of the programs and to prioritize the importance of the different services they offer. A large-scale study could identify the accessibility of the programs, factors that prevent or promote their use, common obstacles they face in fulfilling their tasks, rate of admission to residency and post-residency deployment to underserved communities. Qualitative research could illuminate the experiences of individual non-USIMGs as they navigate the pre-and post-residency process. In the meantime, the programs identified here have the potential to help remediate the physician shortage, increase diversity in the medical profession, and address issues of health equity in the US.

Limitations

This scoping review has two limitations. First, the review excludes organizations that provide information for health professionals but do not provide services toward US medical licensure. Second, this review does not include for-profit career assistance programs.

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