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

Margaret Akey; Brian Groves; James C. Hudspeth; Tracy L. Rabin; Sarah Cortez; Rebecca Silvers; Joseph Novotny; Fekir Negussie; Patti Orozco; Phuoc Le; Riya Sawhney; Nakul Raykar; Michelle Arteaga; John A. Davis Rodriguez; Maureen Curran; Susan Byekwaso; Faysal Saab; Norkamari Shakira Bandolin; Michael S. Lipnick

doi:10.5334/aogh.5020

Figures & Tables

Illustrating pathways for international medical students, arranged side by side. Each pathway starts with visa type, followed by an arrow to state medical license eligibility, and then an arrow to whether patient contact is permitted.

Illustrating pathways for international medical graduates with less than 3 years of residency training, arranged side by side. Each pathway starts with visa type, followed by an arrow to state medical license eligibility, and then an arrow to whether patient contact is permitted.
**Abbreviations:** ACGME, Accreditation Council for Graduate Medical Education; IMG, international medical graduate; ECFMG, Educational Commission for Foreign Medical Graduates; USMLEs, United States Medical Licensing Examinations.

Illustrating pathways for international medical graduates with greater than or equal to 3 years of residency training. Each pathway starts with visa type, followed by an arrow to state medical license eligibility, and then an arrow to whether patient contact is permitted.
**Abbreviations:** ACGME, Accreditation Council for Graduate Medical Education; USMLEs, United States Medical Licensing Examinations.

Table 1

Barriers and Enablers to short‑term clinical training opportunities.

BARRIERS
Immigration / Visas
Visa approval is not guaranteed
Expensive and time‑consuming visa application process (recommended to start 1 year in advance)
For IMGs: visa processes are more complex due to the requirement of a CA Medical License or Special Permit for clinical interactions
CA Medical License
Need US SSN or Individual Taxpayer Identification Number
Need fingerprint clearances from both the DOJ and the FBI
California’s Special Permits can be challenging to use due to their limits within a given visa category
Variability in medical licensing requirements and recognition of qualifications across countries
Funding
Salary/stipend considerations
Travel and transportation costs
Sustainability of funding for training programs
Cost of living/housing in the host country
Restrictions imposed by donors on how funds can be used (e.g., funds designated for research supplies only)
Institutional funding limited to supporting US trainee activities
Limited access and cost of malpractice insurance, general liability insurance, health insurance, and medical evacuation insurance
May need passports and proof of address for banking services
Lack of US credit history makes it difficult to obtain credit cards
US Institutional Capacity
Concern over displacing local students and residents from training opportunities
Tailoring clinical supervision according to individual’s needs
Extensive paperwork: emails, letters, announcements, and coordination with multiple departments
Setting up review committees and rubrics for applications
Arranging clinical visits across multiple hospitals with different policies
Supporting visitors in adjusting to cultural differences
Established programs are easier to manage, while new programs face greater hurdles
Visitor Logistics
Adjust to new environments, including transportation, food, language, community, and spiritual needs
Family considerations, including whether spouses or children can be supported by the program to come to the US
Vaccination status and health clearances
LMIC Institution Capacity
Some LMIC institutions can partially or fully fund their trainees, which can be an incentive for US institutions but may limit partnerships to better‑resourced partners
Determining the training experience desired by LMIC partners vs. what the host institution can offer
Differences in medical curricula and years of training across institutions (e.g., the experience of a 4th‑year medical student varies)
LMIC institutions lack the capacity to cover the workload of the traveling IMG
Political Climate
Support for global health programs can wax and wane with changes in leadership and political priorities
ENABLERS
Immigration / Visas
International medical students can come to the US for hands‑on clinical experience using a B‑1 visa
Small number of existing visa pathways for IMGs (e.g., J‑1, H‑1B, E‑3, TN, O‑1A) for specific use cases. See Figures 1–3 for visa pathways.
CA Medical License
California’s Special Permits enable IMGs to interact with patients in clinical settings
Funding
Expand US university‑affiliated grant criteria to allow funding for international partners
Structure program descriptions to demonstrate institutional value, thereby allowing visiting trainee expenses to be classified as business expenses
Revenue generation for global health programs can be achieved through institutional fees, grants, corporate sponsorships, clinical services, alumni donations, and other innovative partnerships
Open bank accounts for international medical students and IMGs via university‑affiliated credit unions
Administrative Support
Collaborate with global health programs that have successfully managed international exchanges
Intentional and compliant sponsorship letters for the Medical Board of CA and visa support letters for the US State Department
Establish institutional training affiliation agreements to facilitate bidirectional global health partnerships
Personal Considerations
Provide comprehensive orientation programs to make international medical students and IMGs feel welcome
Offer city exploration programs to help international medical students and IMGs acclimate to their new environment
Variability in Needs of LMIC Institution
Programs that prioritize the needs of LMIC partners in the design of training programs
Training Level
IMGs have more experience than international medical students facilitating easier transition

[i] Abbreviations: CA, California; DOJ, Department of Justice; FBI, Federal Bureau of Investigation; IMG, international medical graduate; LMIC, low‑ and middle‑income country; SSN, Social Security Number.

Table 2

CA Special Permits.

NAME OF PERMIT	# ISSUED IN 2024 IN CA	PURPOSE OF LICENSE	TIME RESTRICTIONS	LOCATION RESTRICTIONS	QUALIFICATIONS
Special Faculty Permit 2168	6	For IMG physicians sponsored by the dean of a California School of Medicine, recognized as academically eminent, who do not meet licensure requirements for unrestricted CA medical license.	None mentioned.	Practice is restricted to the sponsoring medical school and its affiliated institutions.	Full‑time appointment at the level of full professor (or equivalent) in a tenure track at a California medical school approved by the Board. Graduated from a medical school recognized by the Medical Board of California. Completed at least 3 years of basic postgraduate residency training. Hold a license to practice in another state, Canadian province, foreign country, or jurisdiction. Not held a position under Section 2113 for 2 years prior to application. Have a US SSN or ITIN prior to issuance of a permit. Fingerprint clearances from DOJ and FBI prior to issuance of a permit.
Special Programs 2111	21	For IMGs seeking postgraduate medical school study in California under the title of “visiting fellow.”	3 years, renewable annually.	Restricted to professional activities within the appointed California medical school.	Graduated from a medical school recognized by the Medical Board of California. Completed at least 3 years of basic postgraduate residency training. Have a US SSN or ITIN prior to issuance of a permit. Fingerprint clearances from DOJ and FBI prior to issuance of a permit.
Special Programs 2112	1	For IMGs participating in a fellowship program in a specialty or subspecialty field.	Issued for 1 year, renewable up to four times.	Restricted to hospitals in California approved by the Joint Commission.	Graduated from a medical school recognized by the Medical Board of California. Have a US SSN or ITIN prior to issuance of a permit. Fingerprint clearances from DOJ and FBI prior to issuance of a permit.
Special Programs 2113	7	For IMG physicians with a full‑time faculty position, allowing practice incidental to their faculty duties.	1 year, renewable twice.	Restricted to within the host institution.	Graduated from a medical school recognized by the Medical Board of California. If from a non‑US/Canadian school: at least 4 years of licensure, practice in an approved US facility, or a combination. Have a US SSN or ITIN prior to issuance of a permit. Fingerprint clearances from DOJ and FBI prior to issuance of a permit.

[i] Abbreviations: IMG, international medical graduate; CA, California; SSN, Social Security Number; ITIN, Individual Taxpayer Identification Number; DOJ, Department of Justice; FBI, Federal Bureau of Investigation.

Table 3

Overview of visa pathways permitting hands‑on clinical training for international medical students and IMGs.

	STUDENT AND EXCHANGE VISITOR
VISA CATEGORY	F‑1 STUDENT	J‑1 STUDENT DEGREE	J‑1 ALIEN PHYSICIAN	J‑1 RESEARCH SCHOLAR/PROFESSOR
Visa Purpose	Full‑time education	Full‑time education, bachelors, masters, PhD, doctorate	Residency and Fellowship Training	Research Scholar: Focused on conducting research or consulting at research institutions Professor: Primarily teaching, lecturing, or consulting at accredited academic institutions
Medical Training/ Employment Use	US Medical School	US Medical School	ACGME‑accredited residency, fellowship, and non‑standard training programs	Primary purpose is participation in non‑clinical programs for observation, consultation, teaching, and research
Possibility for Clinical Contact	Yes, if patient contact is required for the curriculum	Yes, if needed for degree completion Patient contact does not require approval if the university can issue Form DS‑2019 for J‑1 students	Yes, within ACGME limitations	Yes, if: Program focuses on observation, consultation, teaching, or research Patient contact supervised by a licensed US physician No final responsibility for diagnosis or treatment Compliant with State licensing rules Experience does not count toward board certification
*How visa cannot* be used**	GME Residency/Fellowship Physician employment	GME Residency/Fellowship Physician employment	Clinical research outside approved GME programs Clinical fellowships/activities by non‑ACGME programs No employment beyond approved training program (i.e. moonlighting)	GME Residency/Fellowship No employment beyond approved training program (i.e. moonlighting)
Required before applying for US Visa	Completion of all standard educational prerequisites Official school acceptance Proof of sufficient financial resources to cover attendance costs Form I‑20 issued by the sponsoring university	Completion of all standard educational prerequisites Official school acceptance Proof of sufficient financial resources to cover attendance costs Majority of funding must come from external, non‑personal, or family sources Form DS‑2019 issued by the sponsoring university	Valid ECFMG certificate Completion of USMLE Steps 1, 2CK, 2CS Statement of need from the Ministry of Health Official GME residency/fellowship contract Form DS‑2019 issued by ECFMG	Minimum bachelor’s degree with relevant research or teaching experience Offer letter Certification from medical school dean regarding incidental patient contact
Duration of US Stay	Normal full‑time study (typically 4 years) 1–3 years of optional practical training possible post completion	Normal full‑time study (typically 4 years) Up to 36 months of academic training possible post‑graduation	Time to complete US board certification in the specialty (up to 7 years)	Up to 5 years

	SELF‑SPONSORED
VISA CATEGORY	B‑1	VISA WAIVER PROGRAM (AS WAIVER BUSINESS)
Visa Purpose	Business Visit	Business Visit
Medical Training/Employment Use	Business consultation Conference attendance Interview Non‑clinical observership Short‑term medical clerkship for international students	Business consultation Conference attendance Interview Non‑clinical observership Short‑term medical clerkship for international students
Possibility for Clinical Contact	Yes, only for medical students on approved clerkship rotation at a US medical school	Yes, only for medical students on approved clerkship rotation at a US medical school
*How visa cannot* be used**	GME Residency/Fellowship Research Employment Any compensated activity or service	GME Residency/Fellowship Research Employment Any activity or service for compensation
Required before applying for US Visa	Travel plan/itinerary Employer letter or invitation/registration proof for business, educational, or commercial event	Travel plan/itinerary Employer letter or invitation/registration proof for business, educational, or commercial event
Duration of US Stay	Typically 6 months	90 days

	EMPLOYER‑SPONSORED
VISA CATEGORY	H‑1B	H‑1B PHYSICIAN OF INTERNATIONAL RENOWN	O‑1A	E3	TN
Visa Purpose	Specialty occupation, sponsored by US employer	Clinical physicians seeking H‑1B nonimmigrant visas	Extraordinary ability. Individuals that have risen to international acclaim in their field	For citizens of Australia to work in specialty occupations with US employer sponsorship	For citizens of Canada or Mexico to work in identified occupations in the US
Medical Training/ Employment Use	GME residency and fellowship programs Postdoctoral trainees Physician employment Faculty in non‑ACGME programs	Physician employment Faculty in non‑ACGME programs	Work clinically as a physician, must also possess state license	GME residency and fellowship programs Postdoctoral trainees Physician employment Faculty in non‑ACGME programs	Allows qualified Canadian and Mexican citizens temporary entry into the US for professional business activities
Possibility for Clinical Contact	Clinical work requires USMLEs and approved CA medical license/permit Teaching roles with incidental patient contact require a CA medical license/permit, but not USMLEs	Yes, if demonstrates national or international renown per USCIS evidence list	Yes, does not require USMLEs	Yes, with state medical license/permit	Only for teaching/research; patient interaction must be incidental
*How visa cannot* be used**	Unpaid work	Unpaid work	Physicians who have not met the requirements for O‑1	Unpaid work	Primary purpose of patient care
Required before applying for US Visa	Applicant must have 4 credit years or an MD equivalent Medical school must meet requirements via https://www.wdoms.org/ For clinical work: USMLE Steps 1, 2CK, 2CS, and 3 required For teaching: No USMLE if clinical contact is “incidental” per Department of Homeland Security Approved state medical license for the work	Approved state medical license appropriate for the work activity No USMLEs if they demonstrate qualification under the national or international renown standard	Sponsoring employers must show that O‑1 visa recipients have a major internationally recognized prize or meet at least three USCIS eligibility requirements	Must be an Australian national Must have an approved Labor Condition Application from the Department of Labor Employment must qualify as a “specialty occupation” Must have the necessary academic qualifications Must intend to leave the US when E‑3 status ends Must have a state license	Proof of Canadian or Mexican citizenship MD or Doctor en Medicina; State/Provisional license (post‑entry) Employer letter (role, purpose, duration, qualifications) Credentials evaluation (if applicable) TN employer files Form I‑129, then apply for TN entry Canadian: Enter US in TN status at port of entry Mexican: Apply for TN visa at US embassy/consulate
Duration of US Stay	Maximum 6 years, with extensions Issued in 3‑year increments	Maximum 6 years, with extensions Issued in 3‑year increments	Initial stay of 3 years, with annual 1‑year extensions	Up to 2 years per extension	3 years initially, extendable in 3‑year increments

[i] Abbreviations: ACGME, Accreditation Council for Graduate Medical Education; CA, California; DOJ, Department of Justice; DS‑2019, Certificate of Eligibility for Exchange Visitor (J‑1) Status; ECFMG, Educational Commission for Foreign Medical Graduates; FBI, Federal Bureau of Investigation; GME, Graduate Medical Education; IMG, international medical graduate; I‑20, Certificate of Eligibility for Nonimmigrant Student Status; MD, Doctor of Medicine; SSN, Social Security Number; USCIS, US Citizenship and Immigration Services; USMLE, United States Medical Licensing Examination; VWP, Visa Waiver Program.

Table 4

Summary of recommendations for equitable short‑term clinical training programs for international medical students and IMGs.

STAKEHOLDER	CURRENT STATUS	PROPOSED REFORMS
International Medical Students	Limited clinical rotation opportunities	Advocate for California medical schools to expand visiting student programs to include international medical students Encourage US medical institutions to dedicate funding and efforts to bring LMIC students to the US when creating global health exchange programs
IMGs with < 3 Years of Residency	Severely restricted clinical practice; CA 2112 Special Permit exists but rarely used (only one permit issued in 2024)	Increase awareness and use of California’s Special Permits for IMGs through targeted outreach, partnerships with global health networks, and institutional incentives to expand bidirectional clinical training programs Expand California’s Special Permits to include a new category allowing supervised clinical interactions for short‑term global health exchanges Within this new Special Permit category, include graduates from international medical schools not currently recognized by the Medical Board of California to increase IMG participation from LMICs
IMGs with > 3 Years of Residency	Pathways exist, but are complex; limited short‑term opportunities due to visa and licensing restrictions	Advocate for a new J‑1 visa category for short‑term clinical exchanges Propose regulatory changes to permit supervised “incidental” patient care under J‑1 Research Scholar/Professor and H‑1B visas, defined as supervised clinical interactions without final responsibility for patient care and in compliance with state licensing laws Establish a universal framework for temporary short‑term training licenses across state medical boards
CA Academic Medical Centers	US institutions focus primarily on outbound programs; funding and administrative capacity for inbound exchanges are often lacking	Designate global health exchanges as a mission priority Dedicate budget and staff for inbound IMGs and students Commit to even small‑scale programs (1–2 trainees/year) Pursue external fundraising where internal funds are limited Simplify legal agreements for partnerships Create grant opportunities specifically for LMIC partners
LMIC Partner Institutions	Programs are often designed primarily by US institutions, with LMIC partners in supporting roles	Ensure LMIC partners lead design of exchanges aligned with local priorities. Focus exchanges on building LMIC health system capacity Avoid programs that incentivize permanent migration (“brain drain”)

[i] Abbreviations: CA, California; IMG, international medical graduate; LMIC, low‑ and middle‑income country.

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

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