Getting licensed in United States

Main route

ECFMG certification and US residency (the standard route)

Who it is for: IMGs who want to train and practise in the US through accredited residency, including recent graduates and doctors at any career stage.

1. 1

   Step 1

   Confirm your school is eligible and register for the USMLE through the FSMB

   Your medical school must be listed in the World Directory of Medical Schools as meeting ECFMG's eligibility requirements, and ECFMG decides whether you are eligible for certification. Since January 12, 2026, IMGs register for all USMLE Steps through the Federation of State Medical Boards (FSMB) instead of ECFMG. ECFMG certification also requires your final medical diploma and transcript to be verified.

   Run by

   USMLE program (registration for IMGs through FSMB)

   Where people get stuck

   • Working out your school's eligibility listing can be confusing, especially if the school changed its name or merged.
   • The 2026 move from ECFMG's portal to FSMB's means many older guides and videos show the wrong steps.
   • Your diploma and transcript have to be confirmed directly with your school, and some schools respond slowly.

   What it opens up

   • Access to USMLE Step 1 and Step 2 CK registration
   • A record with ECFMG that later supports certification, ERAS and J-1 sponsorship

   SourcesUSMLE: EligibilityUSMLE: Service transition launching January 2026USMLE: Apply for examsNRMP: IMGs in the Match (eligibility and verification)

   United States
2. 2

   Step 2

   Pass USMLE Step 1

   Step 1 is the first USMLE exam and one of the two exams ECFMG requires for its medical science requirement. Since January 26, 2022, results are reported only as pass or fail. Testing outside the US and Canada costs an extra region fee.

   Run by

   USMLE (co-sponsored by FSMB and NBME)

   Fee

   USD 695 application fee, plus a USD 210 region fee if you test outside the US and Canada (usmle.org, 2026 and 2027 fees, checked 2026-10-17)

   Where people get stuck

   • Because Step 1 is pass/fail, IMGs need other ways to stand out, such as their Step 2 CK result, US clinical experience and letters.
   • A failure stays on your transcript and can be hard to explain to programs.
   • Attempts are limited: four or more attempts at any Step without passing make you ineligible for the USMLE, and you cannot take the same Step more than three times in 12 months.

   What it opens up

   • Half of ECFMG's medical science exam requirement
   • One of the prerequisites for Step 3

   Practise for this exam on MedReadySee availability in the app

   Official practice for this exam

   SourcesUSMLE: Step 1 pass/fail score reporting implementation dateUSMLE: Eligibility (attempt limits)USMLE: Apply for exams (fees)

   United States
3. 3

   Step 3

   Pass USMLE Step 2 CK

   Step 2 Clinical Knowledge (CK) is the second exam ECFMG requires for its medical science requirement, and it still reports a three-digit score. The passing standard was raised for exams taken on or after July 1, 2025. The separate Step 2 Clinical Skills exam was discontinued in 2021 and is not coming back.

   Run by

   USMLE (co-sponsored by FSMB and NBME)

   Fee

   USD 695 application fee, plus a USD 235 region fee if you test outside the US and Canada (usmle.org, 2026 and 2027 fees, checked 2026-10-17)

   Where people get stuck

   • Programs can see the score, so many IMGs feel pressure to delay the exam until they feel fully ready.
   • US-style clinical cases and management approaches can differ from practice at home.
   • The exam day is long and demanding, especially if you have to travel to a test centre.

   What it opens up

   • Completes ECFMG's medical science exam requirement
   • A score that residency programs can review

   Practise for this exam on MedReadySee availability in the app

   Official practice for this exam

   SourcesUSMLE: Change to Step 2 CK passing standard begins July 1, 2025USMLE: Work to relaunch Step 2 CS discontinued (Jan 26, 2021)USMLE: Service transition (ECFMG still requires Step 1 and Step 2 CK)USMLE: Apply for exams (fees)

   United States
4. 4

   Step 4

   Meet ECFMG's clinical and communication skills requirement and get certified

   Because Step 2 CS no longer exists, ECFMG checks clinical and communication skills through its Pathways, and the OET Medicine English test is part of every Pathway. To be ranked in the NRMP Match, ECFMG must confirm that you have met the medical science, clinical skills and communication skills requirements. Full ECFMG certification, which also needs your verified diploma and transcript, is required to start an accredited residency.

   Run by

   ECFMG (a division of Intealth)

   Timing

   OET results in about 12 days (oet.com). ECFMG sets its own deadlines for each Match year.

   Where people get stuck

   • Pathway rules, eligibility dates and deadlines change every Match year, and ECFMG's own site is the only reliable source.
   • OET Medicine has its own healthcare-based format for listening, reading, writing and speaking, and it needs specific preparation.
   • Missing an ECFMG deadline can mean waiting a full year for the next Match.

   What it opens up

   • ECFMG verification that lets you be ranked in the NRMP Match
   • ECFMG certification, needed to start an accredited residency and to sit Step 3
   • Eligibility for ECFMG's J-1 visa sponsorship, if your program uses it

   SourcesOET: OET for ECFMG certificationNRMP: Eligibility requirements (2027 Match)NRMP: Do I have to be ECFMG certified to participate in the Match and SOAP?NRMP: IMGs in the Match (ECFMG certification needed to begin training)USMLE: Eligibility (Step 3 requires ECFMG certificate)

   United States
5. 5

   Step 5

   Apply to residency programs through ERAS

   ECFMG acts as the Designated Dean's Office for IMGs. It issues your ERAS token, which you use to register on MyERAS, and uploads your ECFMG status report to the programs you apply to. In the 2027 season, ECFMG issued tokens from June 24, 2026, applicants could submit from September 2, 2026, and programs could start reviewing on September 23, 2026.

   Run by

   AAMC ERAS (ECFMG for IMG documents and tokens)

   Timing

   Once a year. For the 2027 season, applications were submitted from September 2, 2026.

   Fee

   USD 11 per program for the first 30 programs in each specialty, then USD 30 per program (AAMC fees for the 2027 ERAS season, checked 2026-10-17)

   Where people get stuck

   • Some programs do not sponsor visas or rarely interview IMGs, so check each program's criteria before you pay to apply.
   • US clinical experience and US letters of recommendation are hard to get from abroad.
   • Costs add up quickly across many programs and specialties.

   What it opens up

   • Interview invitations from residency programs
   • A complete application for programs to review ahead of the Match

   SourcesAAMC: 2027 ERAS residency timeline for IMGsAAMC: Fees for the 2027 ERAS season

   United States
6. 6

   Step 6

   Register and rank in the NRMP Main Residency Match

   You register with the NRMP, interview, and certify a ranked list of programs. For the 2027 Match, ECFMG must confirm your exam and skills requirements by the rank order list certification deadline of March 3, 2027. Match Week and SOAP run March 15-19, 2027, with Match Day on March 19. If you need a visa, confirm before ranking a program that it sponsors the visa type you need.

   Run by

   National Resident Matching Program (NRMP)

   Timing

   2027 Match: rank order list certification deadline March 3, 2027; Match Day March 19, 2027

   Where people get stuck

   • If ECFMG has not verified you by the deadline, you cannot take part in the Match.
   • Choosing how many programs to rank, and whether to add preliminary positions, is hard without local advice.
   • If you do not match, SOAP week moves very fast, and you may face another full application cycle.

   What it opens up

   • A residency position through the Match
   • A chance at unfilled positions through SOAP if you do not match and are eligible

   SourcesNRMP: Eligibility requirements (2027 Match dates)NRMP: Do I have to be ECFMG certified to participate in the Match and SOAP?

   United States
7. 7

   Step 7

   Secure your visa and start residency

   Non-US citizens usually train on a J-1 visa sponsored by ECFMG, the only State Department-designated sponsor for physicians in US graduate medical education. Some programs sponsor an H-1B visa instead. J-1 physicians in graduate medical training must spend two years in their home country after the program, unless they get a waiver. A presidential proclamation from September 2025 requires a USD 100,000 payment for certain new H-1B petitions. It has been challenged in court and was renewed in September 2026, so check current USCIS guidance.

   Run by

   ECFMG (J-1 sponsor) and US immigration authorities

   Where people get stuck

   • Visa appointment delays and policy changes can push back your start date.
   • The J-1 two-year home requirement limits your options after training unless you get a waiver.
   • Not every program sponsors H-1B visas, and H-1B rules and costs have been changing.

   What it opens up

   • The right to start training in your residency program
   • Supervised US clinical training that state boards count toward licensure

   SourcesUS Department of State (BridgeUSA): Physician programUS Department of State (BridgeUSA): Common questions (two-year home-country requirement)USCIS: Presidential proclamation on restriction on entry of certain nonimmigrant workersWhite House fact sheet (September 18, 2026): H-1B programNRMP: Eligibility requirements (visa sponsorship)

   United States
8. 8

   Step 8

   Pass USMLE Step 3

   Step 3 is the final USMLE exam. You must have passed Step 1 and Step 2 CK and, as an IMG, hold a valid ECFMG certificate. US residency training is recommended but not required before you take it. Many state boards also set a time limit for finishing all Steps.

   Run by

   USMLE (registration for IMGs through FSMB)

   Fee

   USD 955 application fee (usmle.org, 2026 and 2027 fees, checked 2026-10-17)

   Where people get stuck

   • Finding study time around residency work hours.
   • Some state boards limit how long you can take to finish all Steps.
   • If you retake a Step 1 or Step 2 CK you already passed and fail it, you lose eligibility for Step 3.

   What it opens up

   • Completes the USMLE sequence that state boards expect for a full licence
   • Meets a requirement in several state alternative-licence laws for moving to a fuller licence

   SourcesUSMLE: Eligibility (Step 3)USMLE: Apply for exams (fees)

   United States
9. 9

   Step 9

   Get a full licence from a state medical board

   Each state sets its own requirements, including how much accredited postgraduate training IMGs need and time limits for passing the USMLE. Residents usually also need a training licence from the state where they train. California, for example, requires a Postgraduate Training License or a full licence within 180 days of starting an accredited program.

   Run by

   State medical boards (example: Medical Board of California)

   Where people get stuck

   • Rules differ between states, so moving after residency can mean meeting a different training requirement.
   • Boards ask for every credential to be verified with the original source, which takes time.
   • Your visa situation after residency (for example, a J-1 waiver job) can decide which state you get licensed in first.

   What it opens up

   • Independent practice in that state
   • A US licence history to build on when applying in other states

   SourcesMedical Board of California: Physicians and surgeonsUSMLE: Eligibility (state time limits)

   United States