Pathways to Clinical Training Opportunities for International Medical Students and IMGs: The California Experience

International medical students

Several pathways exist for international medical students to train in California (Figure 1). Those enrolled full‑time in US medical schools typically use F‑1 or J‑1 visas and do not require a license to perform clinical care defined within their coursework (e.g., patient histories, physical exams).

For short‑term clinical training, international medical students may enter on a self‑sponsored B‑1 visa to complete a clinical rotation approved by the medical school dean. Under this visa, students are allowed to engage in hands‑on patient care under the supervision of a licensed physician. Compared to IMGs, international medical students face fewer regulatory barriers to clinical participation [24].

Successful implementations of this pathway for international medical students include programs at Stanford and UCLA. Stanford’s International Visiting Student Program makes its electives broadly accessible to international students enrolled in their final year of medical school [25]. UCLA and UCSF Fresno allow clinical rotations for students from international medical schools that have established affiliation agreements with the institution [26, 27]. These TAAs are particularly valuable because they can be structured to promote bidirectional and equitable exchanges, creating reciprocal opportunities for both UCLA students and their international counterparts.

While the pathway for international medical students to participate in short‑term, hands‑on clinical experiences is well established, there remain limited opportunities across California. For example, the AAMC VSLO program lists more than 900 clinical electives statewide, but many California medical schools do not offer these opportunities to international medical students [28–32]. Moving forward, California medical schools should prioritize developing and sustaining bilateral, equitable exchange programs that strengthen global academic partnerships and expand access to clinical training.

IMGs with less than 3 years of residency training

Figure 2 shows the limited pathways for IMGs with under 3 years of residency training. IMGs may enter full‑time ACGME residency programs on J‑1 or H‑1B visas paired with a California PTL. The J‑1 visa requires ECFMG certification, USMLE Step 1 and 2 passage, a home country statement of need, and a CA license or permit, plus a 2‑year return home post‑training [33–35]. The H‑1B visa, employer‑sponsored, allows unrestricted clinical care with USMLE Steps 1–3, graduation from an ECFMG‑recognized school, and a CA license or permit [33, 36]. However, recent federal policy shifts have raised the H‑1B application fee from roughly $2,000–$5,000 to $100,000, a change that could significantly limit institutional use of this pathway unless physician exemptions are clearly defined and applied [16, 17]. No visa currently exists for short‑term, hands‑on clinical training for IMGs. Once an international medical student graduates, the B‑1 visa only permits observerships without direct patient care [24]. This visa discrepancy poses a major barrier to IMG clinical training.

Although the California Special Permit (2112) allows supervised patient care for graduates of recognized international medical schools who have a US SSN/ITIN and fingerprint clearance, it remains rarely utilized. With appropriate visa pairing, this underutilized pathway could be further explored to support short‑term training for IMGs with less than 3 years of residency training.

IMGs with at least 3 years of residency training

Figure 3 shows the pathways identified for IMGs with at least 3 years of residency training from any country. For employment in full‑time ACGME residency or fellowship programs, IMGs may use the J‑1 Alien Physician or H‑1B visas as above, but apply for the 2111 California Special Permit, which allows patient interaction. This 2111 permit requires graduation from a Medical Board of California‑approved school, 3 years of residency, a US SSN or ITIN, and DOJ/FBI fingerprint clearance.

Again, IMGs seeking short‑term training opportunities cannot use the B‑1 visa for hands‑on clinical work, so many programs default to offering observerships, which exclude patient contact [24]. Several non‑ACGME pathways exist for short‑term clinical training, though these “short‑term” programs typically last 1 year, similar to fellowship years. One such non‑ACGME option hires experienced physicians as clinical instructors or visiting professors on the H‑1B visa with the 2113 CA Special Permit, allowing “incidental” patient care related to teaching duties. This pathway is complex, requiring graduation from a Medical Board of California‑approved school, 3 years’ residency, DOJ/FBI clearance, and a US SSN or ITIN—which can only be requested two weeks after arrival, further causing delays. Again, recent federal changes to H‑1B costs add another layer of uncertainty, though exemptions for physicians may apply. The E‑3 and TN visas may also be used for Australian, Mexican, or Canadian citizens, respectively, with the 2113 CA Special Permit [37, 38].

Another option is the J‑1 Research Scholar or Professor visa with the 2111 Special Permit, which allows non‑clinical roles that do not require passing the USMLE exams. According to 22 CFR 62.27(c), the program’s responsible officer must verify that no patient care is provided. Alternatively, the medical school dean must certify the “Five Points Memo,” which ensures that the role involves observation, consultation, teaching, or research; only supervised incidental patient contact; no final responsibility for patient care; compliance with state licensing requirements; and that the experience does not count toward specialty board certification [39]. UCLA, UC Irvine, and Stanford have historically defined “incidental patient contact” as under 20% of program time, but there is no guidance from USCIS [21, 40, 41]. The lack of clarity around what constitutes a “non‑clinical” exchange in the context of this Five‑Points Memo leaves room for interpretation. Clearer guidance from the State Department could expand the use of this model for short‑term clinical exchanges without requiring USMLEs.

Additional visas include H‑1B for Physicians of International Renown and the O‑1A visa for extraordinary ability, both requiring state licensure but not USMLEs [42, 43]. Both options are inaccessible to the majority of LMIC physicians who lack the credentials needed for these pathways, making them impractical for broader use.

Commit to reciprocity and institutional support

California AMCs must prioritize equitable global partnerships by treating the inclusion of international medical students and IMGs as mission‑critical. Commitment to addressing the financial, administrative, cultural, and political barriers can further enable meaningful training opportunities. Even small commitments, such as hosting 1–2 international medical students or IMGs annually per institution, could collectively generate a significant impact.

A key step toward reciprocity is allocating funding to support inbound international students and trainees proportional to outbound US students and trainees. Limited resources can launch impactful programs, and fundraising partnerships with nonprofits and industry can supplement budgets. Formalizing TAAs is vital but often complex. Streamlining these processes and providing dedicated institutional resources, such as administrative support to handle visa and licensing issues, is critical. Grant opportunities targeting LMIC collaborators can further strengthen bilateral partnerships.

Importantly, LMIC partners, who have too often been excluded from shaping these efforts, should lead in defining exchange models. While CA AMCs may prioritize sending students and residents, LMIC institutions may prefer training junior or mid‑career faculty who are positioned to drive long‑term impact in local systems.

Reform visa and licensing policies

Visa and licensing policies require significant reform to expand short‑term opportunities for IMGs. International medical students can use the B‑1 visa for clinical rotations, and this pathway should be more frequently utilized to promote hands‑on clinical training. For IMGs, long‑term advocacy efforts should focus on developing a new J‑1 visa category tailored to short‑term clinical exchanges. One such example is the work of the Coalition for Building Reciprocal Initiatives for Global Health Training (Coalition BRIGHT), which has been working to gather support for a federal J‑1 visa amendment proposal [44]. In the short term, advocacy efforts should prioritize a physician exemption to the recent H‑1B executive order, which could otherwise drastically limit IMG training opportunities that utilize the H‑1B visa.

Other avenues for progress include updating US Department of State guidelines to clarify “incidental” patient care under J‑1 Research Scholar or Professor and H‑1B visas, and solidifying existing pathways for IMGs. Incidental patient care should be defined as supervised clinical interactions where the individual does not have final responsibility for the diagnosis or treatment of patients and is in compliance with state licensing requirements. Creating a national framework for state medical boards to issue temporary short‑term training licenses, like those for US residents, could simplify processes for institutions and IMGs. A full overview of visa options for short‑term clinical training is presented in Table 3.

At the state level, more support is needed for IMGs with less than 3 years of residency. The 2112 California Special Permit, allowing clinical interaction for IMGs with less than 3 years of residency training, is rarely used. Proper visa alignment could unlock its potential. California should also expand Special Permits to include a new category for supervised clinical care during short‑term rotations, including graduates from international schools who are currently not recognized by the Medical Board of California.

Increase awareness and utilization of special permits

Increasing awareness of California’s Special Permits through workshops, webinars, and campaigns can educate IMGs, medical schools, and global health programs and immediately expand opportunities. International students’ offices can guide applicants as clinical training programs are established.

California AMCs could incentivize bidirectional programs with grants or recognition, encouraging permit use and strengthening global health efforts. Global and local consortia, such as the Bay Area Global Health Alliance or the Consortium of Universities for Global Health, are potential forums to bring California institutions together and serve as a model for future advocacy groups.

See Table 4 for a summary of recommendations.