Work as a doctor in the USA as an IMG: ECFMG, USMLE (2026)

• A medical degree from a school listed in the World Directory of Medical Schools that meets ECFMG's requirements for your graduation year (check the sponsor note).
• ECFMG verification of your final medical diploma and final transcript directly with your school.
• Passes on USMLE Step 1 (pass or fail) and Step 2 CK (minimum 218 from July 1, 2025), within four total attempts per Step.
• An accepted Pathway, including OET Medicine with 350 in Listening, Reading and Speaking and 300 in Writing in one sitting, taken on or after January 1, 2025 for the 2027 Pathways.
• If you have held an unsupervised medical license anywhere on or after January 1, 2022, you must use Pathway 1 and send a certificate of good standing from that authority directly to ECFMG.
• All ECFMG exam requirements met within seven years of the first exam you pass, and by the NRMP rank order list deadline (March 3, 2027) for the 2027 Match.
• A valid, unexpired ECFMG certificate to start residency and to sit USMLE Step 3.
• For a full state license: completion of the US postgraduate training your state requires and Step 3. Most licensing authorities require Steps 1, 2 and 3 within seven years.
• Legal permission to train and work, usually a J-1 or H-1B visa if you are not a US citizen or permanent resident.

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• ECFMGECFMG (Intealth)

  International medical graduates

  How to register with the ECFMG

1. 1

   1. Check your school and plan your target specialty and state

   Confirm your medical school and graduation year are eligible in the World Directory of Medical Schools. Then think about specialty and state: IMG-friendly specialties, programs that sponsor H-1B visas and state licensing rules all differ. Doctors who skip this step sometimes pass exams only to find their school is not eligible.
2. 2

   2. Open MyIntealth and apply for ECFMG certification

   Create your MyIntealth account ($110), submit the Application for ECFMG Certification ($580) and pay for credential verification ($220). ECFMG verifies your final diploma and transcript with your school. Slow school responses are a common delay, so start this early.
3. 3

   3. Pass USMLE Step 1

   Register through FSMB, which has run USMLE services for IMGs since January 12, 2026. The fee is $695, plus a $210 region fee to test outside the US and Canada. Step 1 is pass or fail, but a fail stays on your record and residency programs see it.
4. 4

   4. Pass USMLE Step 2 CK with a strong score

   Step 2 CK costs $695 through FSMB, plus $235 to test outside the US and Canada. The pass mark is 218, but programs compare scores, so aim well above it. Results usually arrive in two to four weeks, but USMLE advises allowing eight weeks when planning.
5. 5

   5. Pass OET Medicine and complete a Pathway

   Score 350 in Listening, Reading and Speaking and 300 in Writing in one OET Medicine sitting, then apply to the 2027 Pathways ($945) by January 31, 2027. Licensed doctors use Pathway 1 and need a good standing letter sent directly to ECFMG; others use Pathways 2 to 6 depending on their school. Missing documents mean rejection with no refund.
6. 6

   6. Apply for residency through ERAS

   Buy an ERAS token from ECFMG ($185 for the 2027 season) and apply to programs through the AAMC's ERAS. Programs look at your scores, letters of recommendation, personal statement and US clinical experience, and they invite applicants to interview. Check each program's visa policy before applying.
7. 7

   7. Register for and rank in the NRMP Match

   Register for the 2027 Main Residency Match ($85; registration opened September 15, 2026, with a $50 late fee after January 29, 2027). Certify your rank order list by March 3, 2027. Results come out on March 15 (whether you matched) and March 19 (where), with the SOAP for unfilled positions on March 18.
8. 8

   8. Get your visa and start residency

   Once ECFMG certification is complete, apply for J-1 sponsorship through ECFMG ($370, plus a $220 SEVIS fee for first-time applicants) or follow your program's H-1B process. You also need a state training license or permit as your state requires. Residencies start in July.
9. 9

   9. Pass Step 3 and complete training

   Step 3 is a two-day exam taken only in the US, with a passing score of 200 and a $955 fee. USMLE notes it is usually taken in the first or second year of residency, and most state boards require Steps 1 to 3 within seven years.
10. 10

    10. Apply for your state medical license

    Apply to the medical board of the state where you will practice, with your ECFMG certificate (verified through CVS), USMLE transcript and training records. If you trained on a J-1, you must return home for two years or obtain a waiver such as Conrad 30 before changing to H-1B or permanent residence. Board certification in your specialty is a separate step through the specialty boards.

• USMLE Step 1

  A one-day exam of the basic sciences, taken at Prometric centers in the US and abroad. From May 14, 2026 it has fourteen 30-minute blocks of up to 20 questions in an eight-hour day. Results are pass or fail only.

  Read the guide

• USMLE Step 2 CK

  A one-day, nine-hour exam of clinical knowledge for supervised patient care. From May 7, 2026 it has sixteen 30-minute blocks of up to 20 questions. Minimum passing score 218 for tests from July 1, 2025.

  Read the guide

• OET Medicine

  ECFMG's communication skills test for every Pathways applicant: 350 in Listening, Reading and Speaking, 300 in Writing, in one administration. Available on paper or computer at venues worldwide; OET@Home only where there is no venue in your country.

• Pathways for ECFMG Certification

  The clinical skills requirement. Pathway 1 is for doctors who have held an unsupervised license since January 1, 2022; Pathway 2 for schools with a licensing OSCE; Pathways 3 to 5 for schools meeting accreditation criteria; Pathway 6 requires six in-person patient encounters rated by licensed physicians using ECFMG's Mini-CEX.

• USMLE Step 3

  A two-day exam taken only in the US and its territories. Day 1 (Foundations of Independent Practice) has 232 multiple-choice questions; Day 2 (Advanced Clinical Medicine) has 180 questions and 13 to 14 computer-based case simulations. Passing score 200.

  Read the guide

• OET Medicine is the English and communication test ECFMG requires: at least 350 in Listening, Reading and Speaking and 300 in Writing, in one test administration.
• There are no exemptions for native speakers or graduates of English-medium schools. IELTS and TOEFL are not accepted for ECFMG certification.
• For the 2027 Pathways, the passing OET result must be from a test taken on or after January 1, 2025.
• If you miss the score in any sub-test, you retake all four sub-tests; there is no limit on retakes.
• Provide your MyIntealth ID when booking OET so results are sent to ECFMG; ECFMG advises testing no later than December 2026 for the 2027 Match.

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• ECFMG requires all exam requirements to be met within seven years of your first passed exam, and it does not send reminders as the deadline approaches.
• USMLE results usually arrive two to four weeks after the test; USMLE advises allowing eight weeks.
• The Match runs once a year: for 2027, registration opened September 15, 2026, the Pathways deadline is January 31, 2027, ranking closes March 3, 2027 and residency starts in July 2027.
• Residency length depends on the specialty, and USMLE notes that Step 3 is usually taken in the first or second year of training.
• A 2027 Pathway, and any certificate based on it, expires on December 31, 2029, so plan to start residency or revalidate before then.
• Virginia's provisional license for experienced international physicians lasts up to two years, followed by a restricted license of at least two years before full licensure, according to the Virginia Code.

Median annual wages from the US Bureau of Labor Statistics Occupational Outlook Handbook, using May 2025 Occupational Employment and Wage Statistics (OEWS) data. These are national medians for licensed physicians, not resident salaries; residents are paid stipends set by each training institution. Pay varies widely by state, setting and specialty.

• Residency programs accredited by the ACGME, based at teaching hospitals, academic medical centers and community hospitals. Programs recruit through ERAS and the NRMP Match; some offer positions outside the Match or through the SOAP during Match Week.
• IMGs are heavily represented in internal medicine, pediatrics, pathology, neurology and family medicine. In 2026, ECFMG reports that IMGs filled about 42% of first-year categorical internal medicine positions.
• Each program decides which visas it sponsors. Many sponsor only the J-1 through ECFMG; others also sponsor H-1B. Check before you apply, as this affects where you can realistically match.
• After training, physicians on J-1 waivers usually work for three years at a facility in a federally designated shortage area under a state's Conrad 30 program. These are often community hospitals, clinics and health centers.
• In states with alternative licensure laws, such as Virginia, an experienced internationally trained physician needs a job offer from an eligible medical care facility that runs an assessment and evaluation program. Practice varies by employer.
• Hospitals and medical groups credential every physician through CVS and state board records before you start, including primary source checks of your degree and training.

• J-1 (exchange visitor physician): ECFMG is the only sponsor of J-1 physicians in clinical training. You apply through ECFMG's Exchange Visitor Sponsorship Program ($370, plus a $220 SEVIS fee for initial applicants).
• Two-year home residence requirement: USCIS says J-1 foreign medical graduates must normally live in their home country for at least two years after their program ends before they can get permanent residence or certain visas, under section 212(e) of the Immigration and Nationality Act.
• Conrad 30 waiver: USCIS says J-1 physicians can apply for a waiver of the two-year requirement if they agree to work full time (40 hours a week) in H-1B status for at least three years at a facility in, or serving, a Health Professional Shortage Area, Medically Underserved Area or Medically Underserved Population. Each state runs its own application process.
• H-1B (specialty occupation): USCIS says H-1B workers can generally be admitted for up to three years, extendable to a total of six. The annual cap is 65,000, plus 20,000 for holders of US master's degrees or higher, but employers that are institutions of higher education, their affiliated nonprofits, nonprofit research organizations and government research organizations are cap exempt.
• H-1B payment: USCIS says certain new H-1B petitions filed after 12:01 a.m. Eastern on September 21, 2025 must include an additional $100,000 payment under a Presidential Proclamation. Check the current USCIS guidance with your employer before relying on an H-1B route.
• J-1 duration of status: ECFMG reports that on September 14, 2026 a federal court postponed a Department of Homeland Security rule that would have ended duration of status for J-1 physicians. Check ECFMG's updates before you travel.
• Visa rules change often and this is not legal advice. Use an immigration attorney for your individual case.

1. 1

   Pathway 1: if you hold or have held an unsupervised license from a Gulf regulator such as DHA, DOH Abu Dhabi, MOHAP, SCFHS, QCHP, or the regulators in Oman, Kuwait or Bahrain at any time on or after January 1, 2022, you must apply to Pathway 1. A training, resident or restricted license does not count. A license that was subject to disciplinary action makes you ineligible for Pathway 1.

2. 2

   Good standing letters: ask each Gulf regulator to send its certificate or letter of good standing directly to ECFMG. If ECFMG receives it before you apply, you must submit your Pathways application within 90 days of its issue date, so time your requests and plan for the January 31, 2027 deadline.

3. 3

   What does not transfer: Gulf licenses, Saudi Board, Arab Board and other Gulf specialty certificates do not exempt you from the USMLE, the Pathways or US residency. Credential verification you did for a Gulf regulator (for example through DataFlow) does not replace ECFMG's own verification with your medical school.

4. 4

   Experience: years of practice in the Gulf can matter in states with alternative licensure laws. Virginia's provisional license, for example, requires at least five years of practice after a foreign medical degree, plus ECFMG certification, USMLE Steps 1 and 2 CK and a job offer. Confirm with the state board that your Gulf experience meets its definition.

5. 5

   Exams from the Gulf: Step 1, Step 2 CK and OET Medicine can be taken outside the US, with region fees of $210 and $235 for the two Steps. Step 3 must be taken in the US. Check Prometric and OET venue availability in your country well ahead.

6. 6

   US clinical experience and visas: Gulf posts do not count as US clinical experience, which many programs value. If you will need a J-1, get immigration advice early on how the two-year home residence requirement applies to you, especially if you live in the Gulf but hold another nationality.

• Application plan with every step, fee and deadline

• Document checklist tailored to you, and a review of each document before upload

• Timeline built around the regulator's closure windows and document validity periods

• Help completing the application forms accurately and consistently

• Support with profession-specific evidence, such as the HCPC standards of proficiency mapping

• Guidance on certificates of good standing, references and certified translations

• Preparation for identity checks and declarations on health and character

• Tracking your application and help responding to regulator requests

• Next steps after the decision: exams, adaptation, PIN or licence and your first job

Regulators make all registration decisions and set all fees. Our fee is separate from the regulator's fees, exam fees and translation costs.

What our registration and licensing support includesPackages and fees