A Closer Look at the ABR Alternate Certification Pathway
Experts address the program's promise, practical barriers and perceptions
As radiology groups look for ways to bolster the workforce, the alternate certification pathway, created by the American Board of Radiology (ABR), provides an effective mechanism for integrating experienced physicians into U.S. practice, according to Inas Mohamed, MD, MS, an assistant professor of radiology and associate director of the radiology residency program at University Hospitals Cleveland Medical Center, Case Western Reserve University School of Medicine.
“The alternate pathway introduced by the ABR allows international medical graduates (IMGs) who have completed their diagnostic radiology residency outside the U.S. and Canada to be eligible for board certification after four additional years of training in the U.S.,” Dr. Mohamed wrote in a recent Radiology commentary. “This eligibility requirement can be met by a combination of fellowships, up to three years of residency and/or faculty appointments at the same time.”
Along with its benefits, the alternate pathway also presents hurdles, both for those trying to navigate it and for institutions working to bring these radiologists into practice. Physicians and institutions point to three key issues: unclear timelines and limited guidance for applicants, administrative and visa demands for sponsoring programs, and questions about how training standards are maintained.
Roadmaps and Mentors: An IMG's Experience
Adarsh Ghosh, MD, assistant professor in the Department of Radiology at Nationwide Children’s Hospital in Columbus, described pursuing the alternate pathway in a Radiology article. He noted that while the traditional pathway follows a predictable match timeline—typically beginning about two years before fellowship starts—no standardized timelines exist for the alternate pathway, he noted.
“The variability in timeline makes it challenging to complete the onboarding requirements, including appropriate immigration and work authorization, translating into delays and uncertainty in starting the pathway, which may affect subsequent fellowships,” Dr. Ghosh wrote.
“Besides the variable timeline, there are no ‘official’ resources or guidelines available to IMGs applying to the alternate pathway,” he continued. “As such, I relied heavily on word of mouth from peers in the alternate pathway, online searches for vacant positions, social media forums and networking at academic conferences to navigate the initial application process.”
According to Dr. Ghosh, restarting the alternate pathway after a year or two of research or fellowship can be one of the biggest challenges of the pathway itself.
“I experienced this firsthand after my research fellowship could not be transitioned into clinical training,” he said. “The period was turbulent, financially precarious and required significant personal resilience.”
Dr. Ghosh stressed the value of finding and working with mentors. “Mentors helped me by connecting me with programs that might be able to take me on,” he said, noting that he found success meeting mentors while participating in the RSNA annual meeting in 2021.
“I also had wonderful mentors at my research program, and I reached out via email to other people who had done the pathway,” Dr. Ghosh said. “I was surprised by how much other people were willing to help.”
Dr. Ghosh advises anyone interested in obtaining certification via the alternate pathway to first define their long-term goals and then choose the sponsoring program and visa accordingly. “I probably did it the other way round and hence, experienced hiccups,” he said.
Hurdles and Support: An Institutional Perspective
Integrating IMG radiologists through the alternate pathway requires navigating complex credentialing, licensing and governance processes, according to Dr. Mohamed. “Institutions must work to formalize the alternate pathway as a clear and binding four-year plan, equivalent to a residency, to build trust and ensure a reliable pipeline of staff,” she said.
Dr. Mohamed also noted that institutions may need to adapt internal policies to better accommodate international trainees, including developing standardized onboarding processes, ensuring compliance with visa regulations and allocating resources for administrative support.
“Providing financial assistance for relocation, licensing fees and health insurance is another vital step for institutional support,” she said.
She emphasized the importance of allocating specific budgets to sponsor H-1B visas, which she asserted provide a more stable path to permanent residency than the J-1 visa.
Dr. Mohamed contends that several system-level improvements, starting with clearer, more standardized program expectations, could enhance the accessibility and effectiveness of the alternate pathway.
Greater transparency across programs would be highly beneficial, she noted. Clearly defined curricula, expectations and timelines would allow applicants to make informed decisions and plan their careers more effectively.
“First and foremost, visa-related processes must be streamlined to minimize delays and uncertainty,” she said. “Lawmakers could consider creating a special residency title, similar to the European Union’s Blue Card, to help retain these highly qualified academics in the workforce.”
“First and foremost, visa-related processes must be streamlined to minimize delays and uncertainty. Lawmakers could consider creating a special residency title, similar to the European Union’s Blue Card, to help retain these highly qualified academics in the workforce.”
— INAS MOHAMED, MD, MS
A Rigorous Route for Experienced IMGs
Even with the institutional considerations described by Dr. Mohamed, some remain concerned about training rigor and consistency.
The perception that this pathway is a shortcut compared to traditional U.S. training may be based on a misunderstanding of the program's rigorous requirements, noted Sohrab Afshari Mirak, MD, who contributed to the Radiology commentary along with Dr. Mohamed.
Dr. Afshari Mirak is a PGY 5 diagnostic radiology resident at the University Hospitals Cleveland Medical Center at Case Western Reserve University School of Medicine.
“IMGs often enter the U.S. system with strong clinical backgrounds and add years of subspecialty expertise, making them uniquely well-suited for roles in both academia and rural areas where a broad range of pathologic knowledge is required,” he said. “Their diverse international experiences often enhance their adaptability and provide fresh perspectives and innovative approaches to clinical and research questions.”
Still, some radiologists and program leaders have raised concerns that training standards, clinical expectations and supervision models can vary significantly across countries and institutions. Critics of the expanded alternate pathway argue that not all candidates may be adequately prepared for the pace, technology demands or communication expectations of U.S. practice, particularly in highly specialized academic environments.
That said, outcomes depend on individual qualifications, training background and the quality of the accepting program, Dr. Mohamed noted. “Careful selection processes, robust training environments and ongoing evaluation are essential to ensure consistent standards.”
For More Information
Access the Radiology article, “Alternating Views on the ABR Alternate Pathway,” and related commentary, “The Growing Nationwide Radiology Shortage: Current Opportunities and Ongoing Challenges for International Medical Graduate Radiologists.”
Learn more about the ABR Alternate Pathways to Certification.
Access RSNA’s Beyond the Boards Pro Pack to gain strategies and guidance for preparing residents for the upcoming ABR Diagnostic Radiology Oral Exam.
Read previous RSNA News stories on radiology workforce challenges: