USMLE for international medical graduates: Step 1, Step 2 CK, ECFMG certification and the Match

If you graduated from a medical school outside the United States and Canada, you need ECFMG certification before you can start an accredited US residency, and you need a residency before almost any state will license you. ECFMG certification has four parts: an eligible medical school, verification of your final diploma and transcript, passes on USMLE Step 1 and USMLE Step 2 Clinical Knowledge (CK), and an accepted Pathway, which includes OET Medicine at ECFMG's scores.

Step 1 has been reported as pass or fail only since January 26, 2022. Step 2 CK still gives a three-digit score, with a minimum pass of 218 for exams on or after July 1, 2025, and residency programs compare those scores. Each Step costs $695 through the Federation of State Medical Boards (FSMB), plus a region fee of $210 (Step 1) or $235 (Step 2 CK) if you test outside the US and Canada. ECFMG's own fees for the account ($110), certification ($580), credential verification ($220) and the 2027 Pathways application ($945) add up to $1,855, before the $185 ERAS token. For the 2027 Main Residency Match, you must meet all of ECFMG's exam requirements by the rank order list deadline of March 3, 2027.

This guide walks through the exams, the certification requirements, the Pathways and the Match in the order you will meet them. For the regulator detail, see our page on ECFMG certification for international medical graduates; for jobs, visas and pay, see our guide to working as a doctor in the USA.

Several organizations are involved, and they changed roles in 2026.

• USMLE is the United States Medical Licensing Examination, a program of the FSMB and NBME. It has three Steps.
• FSMB has run all USMLE Step exam services for IMGs since January 12, 2026: registration, score reports and customer service. You apply at usmle.fsmb.org, not through ECFMG.
• ECFMG, a division of Intealth, handles your application for certification, credential verification, the Pathways, ERAS support for IMGs, J-1 visa sponsorship and the certificate itself. It is not a licensing board.
• Prometric delivers Step 1 and Step 2 CK at test centers in the US and abroad.
• The NRMP runs the Main Residency Match; the AAMC runs ERAS, the application system programs use.
• State medical boards issue licenses, after residency in almost every case.

Many older guides still tell IMGs to register for USMLE through ECFMG or to book Step 2 CS. Both are out of date: Step 2 CS was discontinued in 2021 and its clinical skills role is now covered by the Pathways, and registration moved to FSMB in 2026. Our overview of US healthcare for international professionals shows where doctors sit next to the other professions.

USMLE says IMGs are eligible for Step 1 and Step 2 CK if they are officially enrolled in, or a graduate of, a medical school outside the US and Canada that is listed in the World Directory of Medical Schools and meets ECFMG's requirements. In practice:

1. Check your school's sponsor note in the World Directory for your graduation year. If your school or graduation year does not meet ECFMG's requirements, you are not eligible, however good your exam scores. This takes minutes and is the check people most often skip.
2. Open a MyIntealth account ($110, which includes a $50 online notarization of your identification form through NotaryCam). Use your name exactly as on your passport and diploma.
3. Apply for ECFMG certification ($580 for applications from April 1, 2026) and request verification of your final diploma and transcript ($110 each, $220 in total). ECFMG verifies them directly with your school; uploads go through MyIntealth, not by post or email.

Students can start while still enrolled, but certification is only issued once your graduation and documents are verified. ECFMG also requires you to meet all exam requirements within seven years of the first exam you pass, and it does not send reminders.

Step 1 tests the sciences basic to medical practice, with emphasis on the principles and mechanisms of health, disease and therapy. The format changed on May 14, 2026:

Since January 26, 2022, Step 1 has been reported only as pass or fail. USMLE's scoring page says the passing standard on the three-digit scale is 196, but you will see only the outcome. That does not make Step 1 unimportant. A fail stays on your USMLE transcript, programs can see it, and every attempt counts towards the limit. Many IMGs now treat Step 1 as a gate to pass cleanly on the first attempt, and put their score-chasing energy into Step 2 CK.

Step 2 CK assesses the medical knowledge and clinical science you need to provide patient care under supervision. Its format changed on May 7, 2026:

The minimum passing score is 218 for exams on or after July 1, 2025. USMLE reviews minimum passing scores about once every four years. Because Step 1 is pass or fail, your Step 2 CK score is the main standardized number programs use to compare applicants, so aim well above the minimum. There is no official score that guarantees an interview or a match.

USMLE says results are typically available within four weeks of the exam, but advises allowing at least eight weeks. For the Match, that means taking Step 2 CK early enough that your score is on your ERAS application when programs review it, and in any case before the ECFMG requirements deadline in March.

Step 3 comes later

Step 3 is a two-day exam taken only in the US and its territories. USMLE says IMGs need ECFMG certification to be eligible, and it is usually taken in the first or second year of residency. The 2026 and 2027 fee is $955 and the passing score is 200.

You apply for each Step through FSMB and then schedule with Prometric. The fees for 2026 and 2027 on the USMLE site:

USMLE notes that region fees are not retained by the program. For exams taken in India, an 18% goods and services tax has been collected since December 4, 2024.

Attempt limits. You can attempt a Step no more than four times in total, including incomplete attempts. You cannot take the same Step more than three times in 12 months, and a fourth attempt must be at least 12 months after the first and at least six months after the most recent. After four failed attempts on any Step, you are ineligible for all Steps. You generally cannot retake a Step you have passed, except to meet a time limit set by a US licensing authority.

Doctors in the Gulf can sit Step 1 and Step 2 CK at Prometric centers abroad, subject to the region fees; check seat availability in your country well ahead. Step 3 must be taken in the US.

To be ECFMG certified you must meet all of these, and ECFMG must have verified them:

1. Eligible medical school and graduation year, as shown by the sponsor note in the World Directory.
2. Verified credentials: your final medical diploma and final transcript confirmed directly with your school. If a document is not in English and you do not supply an acceptable translation, ECFMG translates it at $52 a page.
3. Medical science exams: passes on Step 1 and Step 2 CK, within the seven-year window.
4. Clinical and communication skills: an accepted Pathway, including a pass on OET Medicine.

When everything is verified, ECFMG issues your certificate. Programs check it at no cost through ECFMG's Certification Verification Service (CVS); a CVS report to a state medical board costs $70. You need a valid, unexpired certificate to start residency and to sit Step 3.

One rule surprises many doctors: Pathway-based certificates expire. A 2027 Pathway expires on December 31, 2029, and a certificate based on it expires with it unless you revalidate or meet ECFMG's requirements for permanent validation. Certificates based on the old Step 2 CS do not expire. Our ECFMG page lists the other ECFMG services and fees, including EPIC verification.

The Pathways replaced Step 2 CS as the way IMGs meet the clinical skills requirement. The 2027 Pathways application costs $945, is not refundable, and must be submitted by January 31, 2027 (Eastern Time) for the 2027 Match. You need an Application for ECFMG Certification with a status of Accepted or Pending Credential Verification before you can apply.

Pathway 1 documents. Each licensing authority must send a Certificate or Letter of Good Standing directly to ECFMG. If it arrives before you apply, you must submit your Pathways application within 90 days of its issue date. ECFMG will not decide an incomplete application, and one still incomplete at the end of the season is rejected with no refund.

OET Medicine is the only English and communication test ECFMG accepts, and there are no exemptions, including for native speakers. You need 350 in Listening, Reading and Speaking and 300 in Writing, all in one test administration taken on or after January 1, 2025. Miss one sub-test and you retake all four; there is no limit on retakes. Take it on paper or computer at a venue; OET@Home is allowed only if your country has no venue. Give OET your MyIntealth ID so results go to ECFMG. Results usually arrive about 10 business days after the test, and ECFMG advises testing no later than December 2026 for the 2027 Match. IELTS and TOEFL do not count, which is different from the UK, where our PLAB guide explains the GMC's English options.

Most US residencies are filled through the NRMP Main Residency Match once a year. Applications go through ERAS; IMGs buy an ERAS token from ECFMG ($185 for the 2027 season), and the AAMC charges its own program application fees on top. The NRMP's 2027 dates for applicants:

The NRMP also charges $30 for each program code ranked beyond 20. Residencies start in July.

How competitive is it? ECFMG reports that in the 2026 Match, IMGs matched to 9,682 first-year positions, about 23.6% of all matched applicants, and non-US citizen IMGs had a match rate of 56.4%. IMGs filled about 42% of first-year categorical internal medicine positions. Your Step 2 CK score, US clinical experience, letters, the timing of your exams and your visa needs all affect your chances. Check each program's visa policy before you apply: many sponsor only the J-1 through ECFMG, while others also sponsor the H-1B.

There is no single timeline, but the order is fixed and the Match runs once a year. A common plan for a graduate starting from scratch:

• Months 0 to 1: check the World Directory, open MyIntealth, apply for ECFMG certification and start credential verification. School responses are often the slowest part.
• Months 1 to 9: prepare for and pass Step 1. Preparation time varies widely with how recently you studied the basic sciences.
• Months 9 to 18: prepare for and sit Step 2 CK, allowing up to eight weeks for the score. Take OET Medicine in the same period.
• September to January: ERAS applications, NRMP registration and the Pathways application by January 31.
• February to March: interviews, ranking by early March, Match Week in mid-March.
• July: residency starts, provided your ECFMG certificate is issued and your visa is in place.

ECFMG says to allow about five business days for a case manager to start reviewing a complete Pathways application and about five more for final review.

Fees you can count on, from the official fee pages:

On top of that come OET Medicine (set by OET), AAMC's ERAS program fees, which grow with the number of programs, interview travel, any resits, and later J-1 sponsorship ($370 plus a $220 SEVIS fee for first-time applicants) and Step 3 ($955).

Most IMGs who are not US citizens or permanent residents train on a J-1 visa sponsored by ECFMG, which carries a two-year home residence requirement afterwards unless you obtain a waiver such as Conrad 30. Some programs sponsor the H-1B, and USCIS says certain new H-1B petitions filed after September 21, 2025 require an additional $100,000 payment. Physicians are not covered by the VisaScreen health care worker certificate rule at 8 CFR 212.15; that requirement applies to nurses and certain allied health occupations, as our VisaScreen guide explains.

Full licensure is state by state, after the postgraduate training your state requires and Step 3. A small but growing number of states, such as Virginia, have created provisional licenses for experienced internationally trained physicians with a job offer. These rules are new and specific, so read the state law and board guidance before relying on them.

If you are a doctor in the Gulf: a DHA, DOH, MOHAP, SCFHS, QCHP or other unsupervised Gulf license held on or after January 1, 2022 puts you on Pathway 1, so ask each regulator to send its good standing letter directly to ECFMG and time it around the 90-day rule. Gulf licenses, Saudi Board and Arab Board certificates do not exempt you from the USMLE or residency. If you are keeping your options open, the doctors hub compares the US with the UK, Ireland, Germany and the Netherlands, and our GMC registration page covers the UK route.