Bridging Physician Shortages in the United States: Supervised Practice Routes for International Medical Graduates

Abstract

Background: To mitigate physician shortages, especially in rural and Health Professional Shortage Areas (HPSAs), a growing number of U.S. states have created supervised licensure pathways that recognize verified foreign training and experience while requiring time-limited, structured supervision before independent practice. These routes aim to expand access without compromising patient safety.

Objective: To describe the design of these state pathways, synthesize standard eligibility, supervision, and conversion models, and translate them into practical access steps for internationally trained physicians (international medical graduates, IMGs).

Methods: We conducted a rapid policy scan of publicly available sources, including the Federation of State Medical Boards (FSMB) tracking resources, state statutes and medical board rules/webpages, and policy journalism. For each state pathway, we abstracted the entry criteria, supervision structure (including duration, site, and oversight requirements), and conditions for conversion to full licensure, and then performed a descriptive synthesis.

Results: Since 2023, at least 17–18 states have enacted “additional pathway” or analogous supervised practice options. Programs converge on: (1) ECFMG recognition and USMLE Step 1–2 at entry (with Step 3 commonly required before unrestricted licensure); (2) verification of 3–5 years of prior clinical practice and/or foreign postgraduate training; (3) employment at approved facilities often an ACGME-affiliated hospital, Federally-Qualified Health Center (FQHC), or HPSA/rural site under a named supervising physician with a filed practice/supervision agreement; and (4) 2–4 years of supervised practice plus clean evaluations and exam completion for conversion. Implementation status, terminology, and reporting obligations vary by state (Figure 1).

Conclusion: Supervised pathways are a credible and safety-conscious mechanism for adding physician capacity where the need is greatest. Their impact will depend on several key factors, including clear “how-to-apply” guidance, supervisor capacity and support, timely board rulemaking/portals, alignment with immigration/visa timelines, and standardized outcome reporting (applicant volume, placement, conversion rates, and patient-safety indicators).