Addressing the Physician Shortage: Postgraduate Licensure (PGL) for Unmatched Medical School Graduates

The American Association of Medical Colleges estimates that there will be a shortage of 17,800 to 48,000 primary care physicians and 21,000 to 77,100 non–primary care physicians by 2034.¹ This shortage is fueled by a variety of factors, including population growth, the aging population, and physician retirement. The groups most affected by the physician shortage are those living in underserved areas and the uninsured.² A major bottleneck in the current US medical education system is the inadequate number of residency slots, which are far fewer than the number of applicants. The 2021 Match had a record high of 48,700 applicants for 38,106 positions.³

To address the physician shortage, the Resident Physician Shortage Reduction Act of 2021 was initially introduced to the US Congress in an effort to add 2000 medical residency positions between 2023 and 2029. Although passage of this bill or similar legislation may be a step in the right direction, it would not provide an adequate solution for the growing physician shortage crisis. Residency positions are funded by the federal government, and finding taxpayer funding for legislation of this nature can be challenging.

Another solution would be to grant limited licenses to physicians who have graduated from an accredited medical school and passed all of the United States Medical Licensing Exams (USMLE I & II) but who have not matched into a residency program, allowing them to work under the supervision of a fully licensed physician who completed residency.⁵ Missouri was the first state to initiate licensure of this nature in 2014 with the Assistant Physician Program. This limited licensure affords medical school graduates the opportunity to secure gainful employment to pay for living expenses and make payments towards costly medical school student loans. Working with a limited license also provides physicians in the program with the opportunity to gain valuable clinical experience before reapplying for the Match while helping address the physician shortage. Similarly, other states have passed similar laws: Arkansas, Kansas, Utah, Arizona, Louisiana, Idaho, and most recently, Tennessee.^6,7 The term “Assistant Physician” may be misleading as patients may confuse these physicians with Physician Assistants (PAs). As such, a better term may be postgraduate license physicians (PGLs). In practice, the physician would be listed as John Doe, MD-PGL or DO-PGL. Examples of such titles in states that have already implemented these positions include “graduate registered physicians” in Arkansas, “bridge physicians”, as the license serves as a bridge to residency, in Louisiana and Idaho, and “graduate physicians” in Tennessee.⁶

PGL licensure would benefit both US medical graduates and foreign medical graduates (FMGs) who have not matched. Many FMGs have been working for years in their home countries in different specialties and subspecialties and could contribute immediately to the healthcare system. For example, an FMG who may have been a practicing dermatologist in another country could be able to secure a PGL position in a dermatology practice in the United States, and eventually possibly secure a dermatology residency. Some states have already implemented policies to utilize FMGs as a means to combat the physician shortage. For instance, Alabama’s new law accelerates the licensure for FMGs by allowing them to apply 1 year earlier in training. Additionally, those who are unmatched may train under supervision of a fully licensed Alabama physician in preparation to reapply for the Match.⁷ PGLs, particularly FMGs, also may help diversify the physician workforce, which studies have shown can result in better patient outcomes.⁸

Some PGLs who do not match may decide to work indefinitely with a PGL license under a fully licensed physician with a salary structure that includes periodic increases over time, similar to how resident physicians are currently paid. As such, hiring PGLs may be more cost effective than hiring nurse practitioners (NPs) and PAs who typically command higher salaries. PGLs could work in tandem with NPs and PAs in supporting practices under the Physician-led team-based care model, which is endorsed by the American Medical Association and the American Academy of Neurology.^2,4 PGLs would not be able to practice independently or lead the team without completing a residency. Although some of the bills that have been passed in some states have time restrictions in terms of how many years a PGL license can be renewed, we believe that a PGL license should be renewable as long as the supervising physician continues to endorse the PGL in their practice, and the individual PGL is meeting state licensing requirements. The passage of PGL bills would cost taxpayers $0 and would actually generate income for the state licensing boards, which would help support their ongoing mission of serving the best interest of the public.

Expanding the number of residency positions and establishing PGL opportunities can help address the physician shortage, improve access to health care, reduce costs, and improve the diversity of the physician workforce. With a graduated pay scale, some PGLs may decide to remain at an underserved practice indefinitely in a PGL position or return as a fully licensed physician once they have completed residency. The addition of PGL positions would provide an option for unmatched physicians to use their clinical skills and foster professional development during a time that would have otherwise been spent in limbo while waiting to reapply for the Match.^4,5