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Breaking Down Barriers: How Tennessee’s New Law Paves the Way for International Medical Graduates

Posted by Paul Saluja | Jun 03, 2024 | 0 Comments

International Medical Graduates (IMGs) play a crucial role in the U.S. healthcare system, comprising nearly one-quarter of all physicians (24.7%). They are essential in mitigating physician shortages, particularly in underserved areas. However, IMGs face significant barriers to licensing in the U.S., making it challenging for them to practice despite their extensive training and experience abroad. A new law enacted in Tennessee may provide a groundbreaking solution to these challenges, offering a more streamlined path for IMGs to obtain licensure and practice medicine in the U.S.

Existing Barriers for IMGs

Two major requirements have historically created substantial obstacles for IMGs:

  1. U.S.-Based Residency Requirement: All IMGs must complete a residency in the U.S., even if they have already completed equivalent training abroad. This requirement often leads to duplicative training, financial strain, and social instability, with some IMGs abandoning their efforts to practice in the U.S.

  2. Visa Sponsorship Challenges: Noncitizen IMGs face difficulties securing visas due to the reluctance of hospitals to sponsor H1B visas, exacerbated by financial constraints following Medicare cuts to graduate medical education. Many IMGs enter the U.S. on J-1 medical trainee visas and can only remain through waiver programs like Conrad 30, which mandates practice in underserved areas in exchange for visa sponsorship.

These barriers contribute to the underutilization of skilled IMGs, with recent evidence suggesting that up to 40% of immigrant medical professionals work in jobs that do not require their degrees, costing billions in lost wages and unrealized taxes annually.

Tennessee's New Law: A Provisional Pathway

In April 2023, Tennessee enacted SB 1451, a groundbreaking law that reduces these barriers by allowing IMGs licensed in other countries to be provisionally licensed to practice in the U.S. without completing a U.S.-based residency. Key requirements include:

  • Certification by the Educational Commission for Foreign Medical Graduates (ECFMG).
  • Passing U.S. licensing exams (USMLE Step 1 and Step 2).
  • Completion of at least a three-year residency program at an accredited international program.
  • Practicing under the supervision of a Tennessee-licensed physician for two years before obtaining an unrestricted license.

This provisional licensing pathway (PLIMG) aligns Tennessee with countries like Canada and the UK, which have successfully implemented similar programs. The new law offers flexibility in hiring IMGs, particularly noncitizens, and seeks to address physician shortages by streamlining the licensing process.

Key Differences and Potential Concerns

Comparing Tennessee's new law with current U.S. IMG policies highlights significant changes:

Current IMG Policy Tennessee's New Law

U.S. residency required

No U.S. residency required

Limited visa sponsorship

Greater visa flexibility

Restricted practice locations

No geographic restrictions

Trainee licenses

Provisional licenses

While the law creates a framework to increase physician supply, several concerns need addressing to ensure it meets its goals:

  1. Distribution in Underserved Areas: Unlike the Conrad 30 program, which mandates practice in shortage areas, Tennessee's law does not specify such requirements for PLIMGs. This could reduce the likelihood of IMGs serving in underserved regions.

  2. Quality of Care: The law mandates supervision by ACGME-accredited residency programs but lacks detailed supervision standards. Ensuring consistent quality of care requires establishing national standards and competencies for PLIMGs.

  3. Worker Protections: The law does not address potential issues such as underpayment or harsh working conditions. Setting standard salaries and ensuring equitable working conditions are crucial for protecting PLIMGs.

Strengthening Tennessee's New Law

To maximize the effectiveness of Tennessee's new law, policymakers should consider:

  • Incentives for Rural Practice: Monetary incentives and partnerships with rural hospitals can encourage PLIMGs to practice in underserved areas.

  • National Standardization: Collaborating with ECFMG to establish core competencies for PLIMGs can ensure quality and consistency in training.

  • Worker Protections: Implementing standard salary guidelines and addressing working conditions can protect PLIMGs from exploitation.


Tennessee's new law represents a significant step forward in reducing barriers for IMGs and addressing physician shortages. By refining the law to include provisions for underserved areas, quality standards, and worker protections, Tennessee can serve as a model for other states. Ongoing research and evaluation will be critical to understanding the law's impact on the healthcare system and ensuring it achieves its intended goals.

For more information or legal assistance, please contact Saluja Law, where we specialize in immigration and healthcare law, helping professionals navigate complex regulatory landscapes.

About the Author

Paul Saluja

Paul Saluja is a distinguished legal professional with over two decades of experience serving clients across a spectrum of legal domains. Graduating from West Virginia State University in 1988 with a bachelor's degree in chemistry, he continued his academic journey at Ohio Northern University, gr...


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