Physician shortages are a growing problem. The American Medical Association estimates that the United States will be short 37,800 to 124,000 doctors over the next 12 years, of which 48,000 will be primary care doctors. There are historical and practical reasons for this shortage. Most obviously, the American population is growing faster than the number of medical professionals. Moreover, the population is living longer than ever before. Driven by the aging of the Baby Boomers, the number of 65 and older citizens has grown by more than a third—over 13 million people—in the past decade. Despite being the smallest age cohort , individuals 65 and older utilize more health care than any other, making up 37 percent of our nation’s total health care expenditures. Having enough providers to care for the population is critical, and right now, much of the country lacks the physicians to provide this care.
To increase the number of providers, advocacy groups have argued for increasing the number of spots in medical school classes and residency programs. Medical schools have responded, increasing class sizes nearly 18 percent since 2012. However, because residency spots are funded primarily by the Center for Medicare and Medicaid Services (CMS) based on the amount of care provided to Medicare patients at each hospital, increasing the number of residency positions requires both the CMS to appropriate money to create said positions and hospitals to care for more Medicare patients. Furthermore, if the number of training spots were doubled for primary care physicians across the country, for example, hospitals would have to ensure each trainee is able to see an adequate number of patients to be clinically competent, which becomes more difficult as the number of trainees increases. Most importantly, there would still be an unavoidable lag time waiting for medical students to go through four years of school then three years of residency training in primary care before they could see patients independently.
In April of 2023, Tennessee Governor Bill Lee signed HB 1312 into law and Alabama quickly followed suit with similar legislation. These laws aim to fix the physician shortage by allowing international medical graduates (IMGs) to practice medicine without needing to repeat their residency training. Under these laws, eligible international medical graduates who have already completed their training abroad, have been practicing medicine independently in their country of origin, and who have passed the U.S. medical licensing exams can apply to practice medicine in American hospitals without having to go through a domestic residency program. Waiving the American residency requirement shaves off between three to nine years of additional training time, depending on the residency program.
For the first two years of practice in the United States, these doctors will be working under a provisional license valid only at medical centers with active residency programs. In effect, this means they will be treating their own patients while being supervised by other board-certified physicians, similar to how many nurse practitioners or physician assistants practice currently. During this period, provider salary, quality measurements, and location of practice are all negotiated at the hospital level. If the supervision period goes well, these providers will attain a license to practice medicine independently in the state at any facility they choose. The logical next step, which is not fully addressed in these laws, is to arrange provider immigration status so that IMGs who have already attained the ability to practice medicine do not experience interruptions in their practice due to immigration snafus.
The typical objection to these sorts of laws is that it is irresponsible or even negligent to allow medical graduates to treat patients who did not undertake training in the United States. To be fair, there is genuine reason for concern about international standards. The scope of practice and duties of specific specialties differs among countries–sometimes greatly–based on the needs of the respective populations and the resources available in each country. However, the laws’ requirements for IMGs to pass U.S. medical exams and practice under board-certified physicians for two years should provide enough protection to assure the quality of care American patients expect from their doctors. That said, other states may opt to require IMGs to sit for specialty-specific board exams–e.g., the general surgery written and oral board exams—at the end of their two-year supervisory period.
Physician shortages are growing, leaving millions of Americans without reliable access to health care. Tennessee and Alabama have enacted viable solutions to combat the lack of access to care, which are fueled by archaic laws that limit the number of residency training positions across the country. Although the best ways to ensure quality and safety will be optimized over time, these laws take a critical first step in expanding access to health care for all.