Preparing for US Boards as an International Medical Graduate

Challenger Corporation is located in Tennessee. While we are a company focused primarily on US board certification, nurse practitioner programs, and US residencies; we do have several residency installations on every continent but Antarctica. We also serve a lot of international medical graduates coming to the US for residency. We published a news article recently about new practitioner licensing laws being adopted in Tennessee, the first in the nation to offer alternate pathways to licensing for experienced practitioners, and it prompted a lot of questions we aren’t really equipped to handle. When we tried to describe the US licensing and board certification, there was head-scratching as people tried to figure out the differences and commonalities between their home board and licensing practices, and the US. We point everyone to the ECFMG.

The rules for international practitioners wanting to live and work in the United States are changing, albeit ever so slowly. The Educational Commission for Foreign Medical Graduates (ECFMG) is still your best resource, whether you are an experienced practitioner making a transition to US practice, or a student working to get into a US residency.

You have two barriers to practice in the United States: licensure and board certification. Licensing refers to a state level license to practice medicine, board certification refers to a proof of competency in a particular specialty - typically gained through serving a residency in the specialty and then certifying via oral and written tests.

Most countries license physicians at a national level - the United States, Australia, Canada, and Germany use regional or state licensing. In the US, the state level licensing system grew out of a need for physician certification in the 1800’s, and early 1900’s in some states. Each state took on physician licensing within its boundaries, and eventually the National Board of Medical Examiners was formed, which sets overall standards for state licensure regimes to meet. But licensure, and the ongoing requirements to stay licensed, reside at the state level. And each state has its own particular quirks and mandated continuing education requirements for physicians - a trend which started in the 1990’s and shows no sign of slowing down.

While some states are members of a consortium called the Interstate Medical Licensure Compact, which can expedite licensing in multiple states, you still have to be licensed in every state you will practice in. For most physicians, that just means applying for a new license if they move to different states. For physicians practicing in multiple states, you have to have a license for each.

Board certification is unrelated to licensure, except that you have to be a licensed medical doctor (among many other requirements) to take the board certification exams. Think of specialty boards like guilds. They come in two parts, the board itself, like the American Board of Emergency Medicine, which sets the standards and administers the tests, and usually a political lobbying organization like the American College of Emergency Medicine, which works on behalf of specialty members to promote good practices, educate, and lobby at state and national levels for fair treatment of specialty members. Doctors are people, and have arguments. Some specialties will have multiple political groups, and some even have competing boards organizations. For an outsider, it gets complicated.

Because specialties act as guilds, one of their functions is to protect the employment and income of members. A specialty will lobby to make employment requirements that necessitate being board certified to hold a position. These can be enforced through insurance regulation, state regulation, national regulation - any avenue available. For instance, while you do not have to be boarded in Emergency Medicine to practice in an emergency room, you won’t be getting a job at an emergency physician contract group or in most hospitals without the certification. You’ll find Internal Medicine and Family Medicine boarded physicians in ER’s, especially in remote or rural areas.

And it gets worse. Some states require a number of years of post-graduate training (which means residency or fellowship) in order to practice, most don’t. Some states will exempt you from licensing examinations if you are boarded in a specialty, most don’t. Most hospitals and employers will require a board certification as a condition for employment, but then some do not.

To alleviate physician shortages, some states are experimenting with different forms of licensure requirements for international medical graduates (IMGs). Tennessee notably has changed licensing requirements for experienced IMGs meeting certain ECFMG criteria to be licensed to practice, without completing a residency. Washington State adopted in May 2023 new laws granting IMGs two-year licenses to practice if they meet certain criteria.

No matter what pathway you are using, you are going to have to take the United States Medical Licensing Exam, in all its forms - USMLE Step 1, Step 2 CK, Step 2 CS. If you are taking the pathway through residency, you will need to be on the Electronic Residency Application Service (ERAS) managed by the Association of American Medical Colleges (AAMC). You will also participate in the National Resident Matching Program (NRMP). You are not going to navigate this all on your own - the ECFMG is still your best resource, and mentors that have made it through all the steps and stages are important.

Go forth and conquer all the forms and applications!