The leading professional organization for doctors of internal medicine is taking an important step toward easing the U.S. physician shortage, creating a path for licensed, foreign-trained doctors to earn specialist credentials without having to repeat their residency training in the United States or Canada.

The move, by the American Board of Internal Medicine (ABIM), echoes our call earlier this year for broader recognition of international physician training. It comes as a growing number of states have started to implement alternative pathways to licensure for internationally trained physicians (ITPs) that also don’t require a U.S. or Canadian residency. As of 2024, international graduates made up 23 percent of all licensed physicians in the U.S. – and that share is growing.

ABIM’s Pilot Pathway E will remove a key barrier to employment for ITPs licensed through these alternative pathways, helping them secure jobs that match their medical training. It could serve as a model for other specialty boards and demonstrate to states and providers alike that alternative licensing programs are viable pathways to certification and employment.

Why this matters

Practicing medicine in the U.S. requires a state medical license. Historically, state licensing boards have required candidates to complete a residency program in the U.S. or Canada. Residency programs offer medical graduates a period of supervised clinical practice, consisting of rigorous training that lasts anywhere from three to seven years. In most states, ITPs, who have already completed residency training abroad, have to repeat years of training in the U.S. or Canada to earn a U.S. license, even though many international residency programs are similar to those in the U.S.

But in recent years, states have been introducing alternative licensing pathways to address the physician shortage. As of August 2025, 18 states had implemented alternative pathways for qualified ITPs to earn licensure, often by practicing while sponsored by a healthcare facility or provider. Similar legislation is pending in 9 more states and counting.

States are rapidly taking these steps because many are short on providers, particularly in primary care specialties and in rural areas. Part of the shortage is due to insufficient residency program capacity, made worse by federal policy, including a cap on Medicare-funded residency program slots. Participating in a residency program requires successfully going through a matching process, in which applicants and programs rank each other and an algorithm matches applicants to programs. In 2025, 9,536 applicants failed to match to a residency program, and 6,291 of those were international graduates. Alternative licensing pathways for ITPs are essential to bypass this residency bottleneck. 

But even after becoming fully licensed through these pathways, ITPs face a critical barrier to employment: They are not eligible to take exams to qualify as board certified in their areas of specialty. That’s because most specialty boards still require candidates to complete U.S. or Canadian residency programs in order to sit for specialty certification exams.

While specialty board certification is not a legal requirement for a licensed doctor to practice medicine, it is often crucial for employment. Health systems, hospitals, and physician groups view board certification to be an important credential that demonstrates competency. What’s more, premiums for malpractice insurance, often covered by employers, are higher for physicians who lack specialty board certification.

ABIM’s new pilot program makes it one of the first specialty boards to remove this barrier to employment and align certification requirements with the emerging trend toward alternative state licensing requirements. The program maintains high standards of competency for candidates – to qualify, ITPs must already be licensed to practice medicine in the U.S. or Canada and have completed additional subspecialty training through a fellowship accredited by the Accreditation Council for Graduate Medical Education (ACGME), meeting “exceptionally qualified candidate” criteria. 

While some other specialty boards offer alternative certification pathways for ITPs, those routes have much stricter criteria. Only ITPs who are academic faculty, who have already been practicing medicine in the U.S. for multiple years, who already hold a specialty board certification in another country, or who were trained in a few select countries can qualify for these pathways.

ABIM’s program allows more ITPs to prove their competency and eligibility for certification.

Specialty board certification pathways like ABIM’s are crucial to the viability of alternative state licensing programs. Without them, newly licensed ITPs would have to repeat their residency to get certified, reducing the incentive to go through the alternative licensing process at all. And providers may have less incentive to sponsor these ITPs for supervised training under alternative licensing pathways, as there would be no clear pathway to certification.

Looking ahead

As the U.S. tries to overcome its physician shortage, qualified ITPs with residency training abroad are a key, untapped resource. As it stands, many qualified physicians in the U.S. are unable to practice medicine at their full capacity due to restrictive licensing and certification requirements. As more states consider alternative licensing programs, alternative specialty certification pathways will be essential to their success and to subsequent ITP employment. ABIM’s pilot certification program, then, comes at a critical moment. All other specialty boards should follow suit.