For decades, the road for International Medical Graduates (IMGs) to US practice has been a rat race, pass the USMLE, get ECFMG certified and enter the all-expenses-paid residency Match. For many capable doctors, that last obstacle is residency, which has become a barrier they could not overcome, leaving them in professional limbo after years working as volunteers or at low-paid jobs.
But the landscape is shifting. In dire need of physicians, particularly in rural and underserved communities, US states are getting creative. They are no longer willing to wait for the federal government to increase residency positions, they need doctors now. North Carolina may be the leader in this trend with a law enacted in 2026. It helps out with a new lifeline: the Internationally-Trained Physician Employee (ITPE) License.
So what’s the legal structure of this new opportunity? This all stems from Session Law 2025-37 / House Bill 67, which was signed into law by Governor Josh Stein back in July of 2025 and officially took effect on January 1, 2026. Consider it a workforce reform package that aims to close gaps in North Carolina’s healthcare system and to reinvigorate its global talent pipeline.
The main act is the Internationally-Trained Physician Employee (ITPE) license. This isn’t a complete, independent license to hang your own shingle. Rather, it’s a limited, work-based credential that permits IMGs to practice clinical medicine in a very narrowly defined arena.
Under this law, an IMG can work in a licensed hospital or medical practice located in a designated rural county (defined as having a population density of less than 500 people per square mile). Your practice is restricted to that particular job and has to be performed under the direct supervision of a fully licensed North Carolina physician who is physically present. The brilliance of the law is its long game: After being licensed to practice under this supervised, limited license for four years with a clean record, you become qualified to apply for a full, unrestricted medical license in North Carolina.
In simple words, North Carolina is saying:
“If you’re an experienced physician trained outside the U.S., and a hospital or rural practice hires you, you may work in North Carolina without repeating U.S. residency and after four years, you may qualify for full licensure.”
This pathway is intended for experienced doctors, not recent graduates. It has set forth an elaborate list of requirements you must meet to be eligible. Let’s break them down:
You must complete at least 130 weeks of medical education
From a medical school recognised through internationally accepted directories (the Board references recognised global medical school listings).
North Carolina requires you to be eligible for ECFMG certification
In practice, that means passing:
because those are core ECFMG exam requirements. The Board specifically references ECFMG eligibility.
You must have either at least 2 years of postgraduate training or at least 10 years of active physician practice, and in addition, at least 5 years of physician experience
This pathway clearly targets experienced physicians and not fresh graduates.
Active Licensure in Good Standing
You must currently hold an active medical license (or one that has been expired for no more than five years) from another country. You should also have been in good standing within the last 5 years.
No disciplinary actions
No pending investigations
You must be legally authorised to work in the U.S. and demonstrate English proficiency.
Prove You’re Capable
There’s more than one way to demonstrate you have the skills. For example, this might involve:
Completing the USMLE (passing Step 3) or
Possessing a certification from a speciality board recognised as valid in the United States or Canada, or
Passing a national licensing examination of a member country of the International Association of Medical Regulatory Authorities (IAMRA).
Before applying, you must have a full-time job offer from either:
A North Carolina licensed hospital, or
A rural physician practice with an on-site North Carolina-licensed physician.
No sponsor = no pathway.
What does a day in the life look like once you have an ITPE license? In other words, you get to do doctor stuff. You will diagnose patients, develop treatment plans and practice clinical medicine within the halls of your sponsoring hospital or clinic.
But the license was carefully bound to protect patient safety and integrate those patients into the US system. The biggest is the supervision requirement. However, you must operate under the direct supervision of a fully qualified physician who is present at your place or practice. This isn’t being a shadow; it’s having a mentor and safety net while you accustom yourself to the US healthcare culture. You can work in:
Licensed Hospitals. Examples include:
• WakeMed Raleigh Campus
• Mission Hospital
• ECU Health Medical Centre
Rural Physician Practices
Be in statutorily defined rural counties, and have an NC-licensed physician physically onsite.
What is all the fuss about this pathway? Because for the right candidate, the benefits are life-changing.
No U.S. Residency Required: Let’s start with the obvious. That allows them to skip the most daunting, time-intensive and uncertain part of the traditional route.
Quick Path to Practising: You can work and use your skills in the US without wasting years applying to a path that requires a full match.
A Straight Shot to Full Licensure: Four years is your finish line. For example, if you are licensed in good standing under the ITPE for four years, your license will automatically convert to a full unrestricted license that allows you to practice anywhere in the state unsupervised.
Rich US Experience: You will be getting invaluable experience in the American healthcare industry. It not only makes you a better doctor but also positions you well for future opportunities, be it academic postings, fellowship training or just a stronger career.
Let’s talk money. The ITPE license is a career path to practice, a job and a competitive salary. You are not the intern; you are a seasoned player.
Salaries are widely variable depending on your speciality, employer and precise location, but the financial outlook is good. Most physicians who take these jobs, particularly in rural hospitals, should make between $150,000 and $250,000 a year. Because of the dire need for physicians in these locations, employers often provide substantial incentives. Relocation packages, signing bonuses, and even student loan repayment programs are not uncommon additions to entice top talent.
Additionally, many of these employers tend to be non-profit hospitals (often in less-populated areas) or critical access facilities, where they can often sponsor cap-exempt H-1B visas. This is a huge plus, as it avoids the annual H-1B lottery and offers a greater certainty for immigration.
This is the best part of North Carolina’s pathway.
After 4 years of successful practice. Under the ITPE license, the physician becomes eligible to apply for a full North Carolina medical license.
There is no additional requirement in the statute for U.S. residency during those four years.
However:
The North Carolina Medical Board still reviews:
• Professional standing
• Competency
• Disciplinary history
• Compliance with practice restrictions before granting full licensure.
If we want to be helpful, we have to be honest. While this pathway is revolutionary, it is hardly a walk in the park. You have to go in eye-opened.”
The next most obvious one is the limitation on locality and employer. Your career is tethered geographically and professionally to your sponsoring organisation for a minimum of four years. If that job or place doesn’t work out, you’re up a creek.
Obstacle number two: board certification. Many employers and insurance panels also require physicians to be board-certified, even with a state medical license. Most US specialities do not allow board certification without completing a US residency. Thus, while you can gain employment in several institutions with an ITPE license, some doors may remain closed for you as well. Finally, the application process itself is new to everyone including the medical board, employers and lawyers. There will be a learning curve, and working through the bureaucracy will take patience and attention to detail.
This resource provides direct medical board application links and verified step-by-step instructions for IMG alternative licensure pathways across U.S. jurisdictions. Each entry includes the specific license type, responsible board, active application portal link, key eligibility notes, and a sequential how-to-apply guide sourced from official board documentation.
| North Carolina | |
| License Type | IMG Provisional License — SB 336 (2025) |
| Licensing Board | North Carolina Medical Board (NCMB) — ncmedboard.org |
| Application Link | ncmedboard.org → Applicants → Apply for a License |
| Key Eligibility Notes | SB 336 (2025) creates a provisional license for qualified IMGs. Requires substantially similar PGT, ECFMG certification, foreign license in good standing, employment offer in North Carolina, USMLE passage, and English proficiency. |
| How to Apply — Steps | Step 1: Confirm SB 336 application is live by contacting the NCMB at (800) 253-9653 or ncmedboard.org. Step 2: Confirm eligibility: ECFMG certified, substantially similar PGT completed, full foreign license in good standing, passed USMLE (confirm which steps required with the Board), English proficiency, and a written employment offer from a qualifying North Carolina health care entity. Step 3: Apply online at ncmedboard.org/applicants/apply-for-a-license. Select the IMG provisional license option. Step 4: Gather and submit required documents: ECFMG certificate, USMLE transcripts, PGT documentation, home country license verification (sent directly from your licensing authority), medical school transcripts, and employment offer letter. Step 5: Complete the required criminal background check and NPDB Self-Query (npdb.hrsa.gov). Step 6: Pay the required application fee. Board reviews and issues the provisional license. ⚠ SB 336 enacted 2025. Verify application portal is live with NCMB before applying. |
| Quick Reference Links | |
| State Bill | NC SB 336 — Bill Summary |
| Medical Board | Board Application Portal |
| FSMB Chart | FSMB IMG Licensure Pathways Chart |
Are you feeling the excitement with a bit of overwhelm? That’s normal. You don’t have to navigate a brand-new, complex pathway like the ITPE license on your own. That’s why a community like IMG Helping Hands has become your biggest asset.
We guide IMGs just like you every step of the way, making the journey through US medical practice a little smoother! We can help you:
Decode the Requirements: We will tell you, based on your unique credentials and experience if you meet NCMB’s standards.
Verifying Credential: The tedious but important verified step for your medical eligibility.
Job Search Strategies: Finding a job is one part of the journey, but securing the right employer who understands this new license and is willing to sponsor you can be another set of calculations altogether. Through networking and targeting the correct rural hospitals for an effective strategy, we can help you.
Get a mentor: Seek out doctors who have followed non-traditional paths and share contact with them.
North Carolina has taken that small step to open the door just a crack for international medical graduates who believed their career in the United States was not possible. The Internationally-Trained Physician Employee license is not simply a law, it’s what happened when we realised that experienced doctors from around the world had so much to offer American communities in need.
Avoiding the requirement to establish a US residency, providing a straightforward four-year route to full licensure, and accompanying substantial financial incentives make this pathway one of the most transformational changes in US medical licensing in a generation.
North Carolina is calling the IMG ready to work. It’s time to answer.
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