An increasing number of IMGs are looking to the U.S. for training, but there are many steps on the road to practicing radiology.
While talent from abroad could expand the pool of qualified radiologists, there are many varying perspectives about this approach to increasing the radiologist workforce. This article aims to educate ACR members about the different steps involved for an international medical graduate (IMG) to be able to practice as a radiologist in the U.S.
ABR certification is an optional program for radiologists, radiation oncologists, interventional radiologists and medical physicists. This certification distinguishes those medical professionals as highly skilled in their respective specialties — having completed rigorous standardized training and successfully passed ABR certification examinations.
For physicians, most certification candidates have trained in programs accredited by the Accreditation Council for Graduate Medical Education (ACGME) or the Royal College of Physicians and Surgeons of Canada (RCPSC). All certificates issued since 2004 are maintained on an ongoing basis by participation in a program (“Continuing Certification”) that requires state (or provincial) licensure, a commitment to lifelong learning and practice improvement, and a demonstration of knowledge and skills within specialties and subspecialties. The specifics of the programs for initial certification and continuing certification are set by the governing body of the ABR and under general guidelines from the American Board of Medical Specialties (ABMS).
Unlike licensure, ABR certification is not required to practice. However, many employers, hospitals and healthcare systems use certification as a criterion when hiring or credentialling.
Although the residency pathway is used by more than 95 percent of candidates for certification, an alternate pathway exists for those who have trained outside of the U.S. and Canada. This pathway is specifically intended to recognize the hard work and achievement of accomplished individuals from many countries around the world.
The house of medicine is feeling the pressure of workforce challenges — and radiology is no exception. In fact, because of the ubiquitous nature of imaging in healthcare, radiologists’ responsibilities are outgrowing the capacity of their own groups and support staff. Although the ABR alternate pathway was not specifically created to address pipeline issues, many physicians believe integrating IMGs would help expand the pool of competent radiologists.
Although the ABR alternate pathway was not specifically created to address pipeline issues, many physicians believe integrating IMGs would help expand the pool of competent radiologists.
An IMG is any physician who received her or his basic medical degree from a medical school outside the U.S. or Canada, regardless of country of citizenship. The number of IMGs looking for medical training in the U.S. has steadily increased in the last few decades — and they face challenges long before their residency application and throughout medical training. The typical diagnostic radiology candidate will have served a clinical year following medical school and subsequently completed a residency of at least three years in their home country.*
Applicants must have certification from the Educational Commission for Foreign Medical Graduates (ECFMG), pass the United States Medical Licensing Examination® (USMLE) and have an active/current state license. They must also have a Sponsoring Department Agreement (SDA) from an institution with an accredited residency which defines the plan for the training pathway. After four years — which could include time as a resident, fellow and/or faculty — the department chair’s attestation of successful completion of the pathway leads to a board-eligible designation. Certification status is not conferred until the individual passes the requisite exams and meets other requirements, including state or provincial licensure.
The ABR criteria for facilitating the certification process were updated in 2022. Changes for applicants included completing the four years of training within eight years (instead of the preapproved four consecutive years), omitting the obligatory four months of nuclear radiology training, and adding the ability to retrospectively include two years of training before the date of application. All ABR’s prerequisites and eligibility requirements for IMGs can be found on its website.
As noted above, physicians must generally meet several requirements, which differ among state medical boards, to obtain licensure including:
Some states offer provisional or restricted licenses, under which an IMG must complete a designated period of supervised practice. To hold a full, unrestricted medical license, all state boards require IMGs to complete at least one year of accredited U.S. or Canadian graduate medical education (GME). Twelve states require two years of U.S. or Canadian GME, and twenty-five states require three years.
Driven by workforce shortages and restrictions on the number of funded U.S. GME residency positions, multiple states (Arkansas, Florida, Idaho, Illinois, Indiana, Iowa, Louisiana, Massachusetts, Minnesota, Nevada, North Carolina, Oklahoma, Rhode Island, Tennessee, Texas, Virginia, and Wisconsin) have enacted legislation to lower barriers to licensure for IMGs. State-specific requirements for initial medical licensure are available on the Federation of State Medical Boards’ website.
Separate from state licensure and board certification, IMGs must obtain a visa to secure their legal right to work and practice medicine in the U.S. Several visa categories, each with its own set of rules and limitations, are applicable to IMGs who seek to train or practice in the U.S.
The J-1 Exchange Visitor visa is the most common route for physicians entering the U.S. for GME. Sponsored by Intealth (formerly ECFMG), J-1 visas are intended to promote educational and cultural exchange. J-1 visas require ECFMG certification (for non-U.S./Canadian graduates), a signed contract from an approved U.S. training program, and a Statement of Need from the Ministry of Health of the physician’s home country. This Statement of Need confirms the physician’s home country needs specialists in the field for which they will be trained and that the physician intends to return once the training is finished. J-1 visas are limited to the time needed to complete the training program with a maximum of seven years.
Other visa options for physicians include H-1B, O-1, and TN visas. H1-B visas are for temporary workers in “specialty occupations” and can allow for a transition to independent practice more easily than a J-1. H-1B visas are also subject to annual caps and require an employer to directly sponsor the physician. Last fall, President Donald J. Trump issued an executive order raising the fee for new H-1B visa petitions to $100,000 beginning in 2026. On Sept. 25, 2025, ACR and 54 other physician organizations wrote to Secretary of Homeland Security Kristi Noem urging her to include physicians among the groups who have an exception to the increased fee. O-1 visas are reserved for physicians who can demonstrate they possess an “extraordinary ability” in their fields, and TN visas are limited to Canadian and Mexican professionals under the U.S.-Mexico-Canada Agreement.
Finally, IMGs, like all physicians, must be credentialed to work at a specific institution before they can treat patients. While licensing is the state-granted authority to practice medicine, credentialing is the process by which healthcare organizations verify the qualifications of physicians and non-physician providers.
Extensive documentation (diplomas; residency, fellowship, and other training certificates; licenses; peer references) with primary source verification from the original institutions must be supplied. In addition, background checks are performed to identify any criminal history or previous disciplinary actions in the National Practitioner Data Bank (NPDB). Privileging (the specific procedures a physician or non-physician provider is approved to perform at an institution) is distinct from but generally happens in parallel to the credentialing process. Finally, an institutional committee (sometimes called the medical executive committee) reviews the physician’s file and makes a recommendation regarding whether to approve the applicant, usually to the institution’s governing board.
The rapid evolution of state licensure for IMGs has sparked intense debate within the medical community. While proponents argue these changes are necessary to solve the U.S. doctor shortage, IMGs moving to and working in the U.S. may contribute to a “brain drain” in their home countries. Some U.S. physicians and organizations have also expressed concerns about how these alternative pathways for IMGs might impact patient care, U. S. physician compensation, and the long-term standards of American board certification. Despite these differing perspectives, the trend toward more flexible licensure pathways appears to be gaining momentum across the country.
*Author’s Note: While the ABR’s IMG Alternate Pathway is available to radiation oncologists, interventional radiologists and medical physicists, this article is focused mainly on diagnostic radiologists because almost all individuals currently enrolled in the pathway are seeking that certification. Readers are encouraged to visit the ABR website for more details on its programs. Also, listen to Wagner discussing his role with the ABR in this RLI Taking the Lead Podcast.
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