The current ABR Alternate Pathway creates unnecessary barriers that discourage qualified international medical physicists from contributing to the U.S. healthcare system

Medical physics, as a highly specialized discipline, has long benefited from cross-border education exchange and international research collaboration. The American Association of Physicists in Medicine (AAPM) has evolved into a globally engaged organization, with members from 89 countries around the world (https://w4.aapm.org/org/). Despite this international presence, the pathway to professional certification for medical physicists in the United States remains largely confined to graduates of Commission on Accreditation of Medical Physics Education Programs (CAMPEP)-accredited graduate and residency programs, most of which are based in North America. This limitation poses significant challenges for internationally trained medical physicists seeking to explore career development in the U.S. healthcare system. Central to this discussion is the American Board of Radiology's (ABR) Alternate Pathway, a certification route designed to provide international candidates with a structured process for achieving board equivalence. The stringent requirement and practical implementation of this pathway has generated considerable controversies. In this debate, Dr. Sagar Regmi and Dr. Amy Shu-Jung Yu present thoughtful arguments on both sides of this important issue, exploring whether the current structure of the ABR Alternate Pathway achieves an appropriate balance between preserving professional standards and promoting international inclusivity. Dr. Sagar Regmi is a Medical Physics Assistant in the Department of Radiation Oncology at University Hospitals Seidman Cancer Center and is currently pursuing CAMPEP-accredited certification in Medical Physics at Department of Physics, Case Western Reserve University, Cleveland, Ohio, USA. He previously served as a Postdoctoral Scholar at the School of Medicine, Case Western Reserve University, and as Visiting Faculty at Department of Physics, Kathmandu University, Nepal. He served as Assistant Professor of Research and Deputy Director of the Research Center for Invention and Innovation (RC-II) at Gandaki University, Pokhara, Nepal. Dr. Regmi received his Ph.D. in Biomedical Engineering from the School of Chemical and Biomedical Engineering, Nanyang Technological University (NTU), Singapore, where his research focused on the effects of shear stress and chemotherapeutic agents on circulating tumor cells. He later worked at the University of Macau, China, on microfluidic applications in oncology. He earned his undergraduate degree in Physics from Fergusson College, Pune, and an M.Sc. in Physics from the University of Pune, India. Dr. Regmi has authored more than 17 peer-reviewed publications and is an Associate Member of AAPM. Dr. Amy Shu-Jung Yu is a Clinical Associate Professor in the Department of Radiation Oncology and the Program Director for the Therapeutic Medical Physics Residency at Stanford University. She earned her B.S. in Physics from National Taiwan University and a Ph.D. in Biomedical Physics from UCLA, completing her residency in Radiation Oncology Physics at Stanford. Dr. Yu is a diplomate of the ABR in Therapeutic Medical Physics, Dr. Yu has received several awards for her contributions to the field, including the 2023 Karen Doppke Award for Women in Medical Physics. She is actively involved in professional organizations, serving on committees within the American Association of Physicists in Medicine and the Society of Directors of Academic Medical Physics Programs. Her contributions focus on developing best practices in medical physics education. Through her commitment to mentorship and educational initiatives, Dr. Yu is dedicated to advancing the field and ensuring high standards of training for future professionals. The practice, standards, and challenges of clinical medical physics are shared across many countries, with international experts playing a significant role in the advancement of the field in radiation oncology, diagnostic imaging, nuclear medicine as well as healthcare safety. Within this context, the ABR has designed the alternate pathway for internationally educated medical physicists to receive board certification and be equivalent to U.S educated medical physicists. Despite its best efforts, the existing framework of the ABR pathway has become more of a barrier than a bridge. This statement argues that the current policy of the alternate pathway of ABR creates unnecessary barriers which discourage qualified and capable international medical physicists from meaningful contributions to the U.S healthcare system. These hurdles are not only difficult to overcome but also, they make workforce shortage worse,1 limit diversity as well as discourage international collaboration.2 While the ABR plays a critical role in upholding high standards of professionalism, ethics, and patient care in medical physics, its alternate pathway has structural issues that undermine its purpose.3 Instead of offering a clear and attainable route for internationally trained experts, the pathway imposes significant, and often insurmountable, financial, logistical, and institutional barriers. These challenges deter many competent professionals from entering the U.S. workforce, at a time when the demand for skilled medical physicists is growing. The mismatch between the pathway's goals and its real-world impact deserves urgent attention. Be employed in the U.S. as a medical physicist. Complete and submit a Structured Mentorship Program application, including a candidate statement, a Sponsoring Department Agreement, and a Training Plan approved by ABR. Pay a non-refundable application fee. Demonstrate educational equivalence to at least a master's degree in medical physics from a CAMPEP-accredited program. Provide evidence of at least one year of clinical employment as a qualified medical physicist in their country of origin. Show credentials as a medical physicist in their country of initial training. Ensure that the sponsoring department is at an institution with a CAMPEP-accredited residency program and that the supervising medical physicist is an ABR diplomate. Engage in a Structured Mentorship Program lasting a minimum of three years. All three years of training preferred at one institution. Training must be completed within six years from the training start date. While these requirements were designed to maintain the rigor and reliability of board certification, their practical implementation creates substantial obstacles for international candidates.3 Below listed unnecessary barriers to entry. One of the most significant hurdles is the necessity for employment in the U.S. and supervision for a minimum of three years by an ABR-certified physicist at a CAMPEP-accredited institution. This limits applicants to a small subset of institutions willing and able to sponsor Alternate Pathway candidates. Many institutions may lack the resources or willingness to sponsor and mentor international applicants, making it exceedingly difficult for qualified individuals to find suitable positions. International medical physicists face significant financial and logistical hurdles when navigating the ABR Alternate Pathway. The non-refundable application fee, travel expenses, visa fees, and relocation costs can be prohibitive. Securing a sponsoring institution adds further complexity, requiring extensive documentation, departmental commitment, and coordination with the U.S. immigration system. These challenges are compounded by the difficulty of obtaining a visa for a three-year clinical training position, especially when such roles are rarely advertised and often unfunded. Together, these barriers introduce uncertainty and discourage many qualified candidates from pursuing certification and contributing their expertise to the U.S. healthcare system.4 Majority of international medical physicists have extensive clinical experience as well as completed rigorous medical physics training programs in their home country. Making a mandatary requirement for these qualified medical physicists professional to undergo additional three Structured Mentorship Program in CAMPEP-accredited institution with ABR diplomates may be redundant and does not necessarily reflect their existing competencies. Many international training programs have their own strict accreditation process which is equivalent to American standards. The professional organizations like UK's Institute of Physics and Engineering in Medicine (IPEM), Australasian College of Physical Scientists and Engineers in Medicine (ACPSEM), as well as the Canadian College of Physicists in Medicine (CCPM), have their own rigorous academic and clinical assessments. But the ABR's Alternate Pathway does not formally recognize these credentials even though the candidates have years of clinical experience as a qualified medical physicist (QMP) in their home country. The lack of recognition can lead to the underutilization of skilled professionals who are otherwise capable of contributing meaningfully to the U.S. healthcare system. Applicants report variability in how institutions interpret the sponsorship requirements, leading to inconsistencies in approval timelines and outcomes. There is no centralized list of participating institutions, nor standardized documentation templates for mentorship and clinical training plans. This lack of transparency creates a further layer of unpredictability, which discourages applicants who are otherwise motivated and qualified. The consequence of these obstacles is clear that highly qualified international medical physicists are either delayed in their career progressions, divert to alternative careers like non-clinical pathways or excluded altogether to contribute to U.S. health care system. The implications extend beyond fairness, potentially hindering innovation, and workforce growth. There are reports of shortages of clinical medical physicists especially in the rural and underserved regions in the U.S.5 By excluding international talents, we worsen the problem—leading to clinical delays, heavier workloads, and reduced access to quality radiological care. Skilled professionals may decide to work in countries like the UK or Australia, where certification is more straightforward and based on proven skills. Several international boards have moved toward more flexible, competency-based certification systems that prioritize clinical readiness over rigid geographic training locations.6 The UK's HCPC (Health and Care Professions Council) recognizes foreign credentials if applicants can demonstrate equivalent training and experience. The Canadian College of Physicists in Medicine (CCPM) allows direct certification for those with comparable experience, including international candidates. Australasian College of Physical Scientists and Engineers in Medicine (ACPSEM) integrates international experience through a streamlined recognition process without requiring a full replication of domestic training. These systems maintain high standards while reducing unnecessary redundancy. The U.S. can—and should—learn from these models, particularly given its reliance on a global scientific workforce. Mutual recognition agreements with equivalent international certifying bodies (e.g., Canadian College of Physicists in Medicine (CCPM, Canada), Australasian College of Physical Scientists and Engineers in Medicine (ACPSEM, Australia) and Institute of Physics and Engineering in Medicine IPEM, UK). Competency-based assessments that allow candidates to demonstrate clinical proficiency through portfolios, exams, or proctored assessments—rather than redundant clinical repetition. Centralized matching and sponsorship resources, including a list of institutions willing to sponsor Alternate Pathway applicants. Transparency and consistency in approval criteria and documentation expectations, so that candidates and institutions can navigate the process with clarity. Pilot programs for fast-tracking experienced physicists from countries with robust regulatory oversight and board certification systems. The ABR has long been a gold standard for ensuring excellence in medical physics. However, in today's interconnected and international scientific landscape, excellence must also mean accessibility, equity, and adaptability. The current ABR Alternate Pathway, while conceptually valid, imposes unnecessary and impractical barriers that discourage international talent from entering the U.S. healthcare system. This system needs urgent reform to align with modern workforce needs, global talent flows, and the evolving nature of clinical training. By streamlining the certification process, recognizing international equivalency, and focusing on actual clinical competence, we can ensure that the U.S. healthcare system benefits from the full spectrum of global medical physics expertise. Let us not allow procedural rigidity to undermine patient care, limit scientific exchange, or delay the deployment of skilled professionals in areas where they are desperately needed. The time has come to update the ABR Alternate Pathway—not to lower the bar, but to open the gate. In recent discussions surrounding the ABR Alternate Pathway for international certified medical physicists, some argue that this pathway creates unnecessary barriers that discourage certified medical physicists from contributing to the U.S. healthcare system. However, this perspective overlooks the critical importance of maintaining high standards in healthcare, particularly in medical physics, which ensures the safe use of radiation in medicine. Firstly, the importance of patient safety: it is important to ensure that patient safety is at the forefront of any healthcare system. Medical physicists play a crucial role in this regard, as they are responsible for the safe and effective use of radiation in diagnostic imaging and therapeutic procedures.7 The consequences of inadequate training or knowledge in this field can be severe, potentially leading to ineffective treatments or harming patients. The ABR Alternate Pathway is designed to ensure that all medical physicists, regardless of their country of origin, possess the necessary knowledge and skills to practice safely within the U.S. healthcare environment. This pathway includes rigorous training that evaluates a candidate's understanding of U.S. standards, regulations, and practices, which may differ significantly from those in their home countries. By requiring international medical physicists to demonstrate their competency through this pathway, we prioritize patient safety above all else. Secondly, variability in international standards: healthcare practices and standards vary widely across countries.8 The training and certification processes of medical physicists can vary in curriculum, clinical exposure, and regulatory oversight. In some countries, the standards for radiation safety may not be as strict as those in the U.S., leading to potential gaps in knowledge and practice. By mandating that international medical physicists complete a three-year training program equivalent to that of graduates from non-CAMEPE medical physics-related majors, we ensure they gain familiarity with U.S. practices, which is for maintaining consistency and patient care. 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