To train as a doctor in the United States after studying abroad, you need to pass USMLE Step 1 and Step 2 CK, meet ECFMG's clinical and communication skills requirements through one of its Pathways (including an English test, OET Medicine), and then obtain ECFMG Certification. You must meet all the exam requirements by the Rank Order List deadline of the Match you enter. Step 3 usually comes later, during or after your first year of residency.

The three USMLE Steps

The United States Medical Licensing Examination (USMLE) is run jointly by the Federation of State Medical Boards (FSMB) and NBME. The table below uses the formats described in the USMLE's 2027 Bulletin of Information; from May 2026, Step 1 and Step 2 CK moved to 30-minute blocks.

Exam What it tests Format Scoring
Step 1 Basic sciences applied to medicine About 280 questions in fourteen 30-minute blocks; one day, about 8 hours Pass/fail since 26 January 2022
Step 2 CK Clinical knowledge for supervised patient care About 316 questions in sixteen 30-minute blocks; one day, about 9 hours Three-digit score; minimum pass 218 since 1 July 2025
Step 3 Knowledge for unsupervised practice Two days: about 232 questions on day 1; about 180 questions plus 13 to 14 computer case simulations on day 2 Three-digit score; minimum pass 200 since 1 January 2024

Source: USMLE, examination results and scoring, and the 2027 Bulletin of Information.

What changed in recent years

  • Step 1 became pass/fail. Because it no longer gives a numeric score, residency programs now look more closely at your Step 2 CK score.
  • Step 2 CS was discontinued. The in-person clinical skills exam ended in 2021. ECFMG now checks clinical and communication skills through its Pathways instead.
  • Registration moved to FSMB for IMGs. The 2027 Bulletin directs students and graduates of international medical schools to register for Step exams through FSMB's USMLE portal. ECFMG's 2026 information booklet says FSMB took over USMLE exam services for IMGs in January 2026.

Who can sit Step 1 and Step 2 CK

You can take Step 1 and Step 2 CK in any order if you are enrolled in, or have graduated from, a medical school outside the US that is listed in the World Directory of Medical Schools as meeting ECFMG eligibility requirements, and you meet ECFMG's other criteria.

Step 3 for international graduates

According to the USMLE Bulletin, IMGs can take Step 3 only after passing Step 1 and Step 2 CK, receiving their medical degree, and obtaining a valid ECFMG Certificate. Most IMGs take it during residency.

Attempt limits

The USMLE limits retakes:

  • If you have attempted a Step four or more times without passing, including incomplete attempts, you are no longer eligible for any Step.
  • You cannot take the same Step more than three times in 12 months. A fourth attempt must be at least 12 months after your first and at least six months after your most recent attempt.
  • Once you pass a Step, you cannot retake it, except to meet a time limit set by a licensing authority.

ECFMG Certification

ECFMG Certification is the standard that US residency programs and state medical boards use to confirm an IMG is ready to enter graduate medical education. ECFMG is now part of Intealth. Certification has three parts.

1. Medical science exams

Pass USMLE Step 1 and Step 2 CK.

2. Clinical and communication skills: the Pathways

You meet these requirements by completing one of six Pathways, all of which require a satisfactory score on OET Medicine, an English test for healthcare professionals:

  1. Pathway 1: you already hold an unrestricted license to practise in another country.
  2. Pathway 2: your school runs an objective structured clinical exam (OSCE) required for licensure, verified by the school.
  3. Pathways 3, 4 and 5: your medical school completes a Clinical Skills Attestation.
  4. Pathway 6: licensed physicians observe and assess you in six real, in-person patient encounters using ECFMG's Mini-Clinical Evaluation Exercise.

For the 2027 Match, ECFMG says your Pathway application and OET scores must reach it by 31 January 2027. Later results may still be processed but may not arrive in time for the Match.

3. Medical education credentials

Your school must be listed in the World Directory with an ECFMG Sponsor Note, you must have been awarded credit for at least four years of medical education, and ECFMG verifies your diploma and transcript with your school. ECFMG's information booklet also sets a time limit for completing the exam requirements, so plan your Steps in a compact sequence.

The WFME accreditation policy explained

You may have read that from 2024, only graduates of schools accredited by a WFME-recognized agency can be certified. The reality is more nuanced.

ECFMG announced in 2010 that it would require accreditation by a recognized agency. After delays, Intealth began implementing its Recognized Accreditation Policy in November 2024. It accepts two systems for recognizing accrediting agencies: the World Federation for Medical Education (WFME) and the US Department of Education's NCFMEA. Schools that meet the policy are flagged in their World Directory listing.

Crucially, Intealth states that the policy currently does not affect an individual's eligibility for ECFMG Certification. You can still apply and become certified if your school meets ECFMG's current requirements, even if it does not yet meet the policy. ECFMG Status Reports sent to residency programs include a general statement about the policy, so programs can see which schools meet it. Choosing a school whose accreditor is WFME- or NCFMEA-recognized remains the safer option.

A realistic timeline

Most IMGs follow a sequence like this:

  1. During basic sciences: prepare for Step 1, usually taken at the end of the pre-clinical years.
  2. During clinical years: take Step 2 CK and, at many schools, apply for a Pathway once eligible. Book OET Medicine early.
  3. Spring and summer before the Match: gather letters and arrange US clinical experience if you can. The 2027 ERAS season opened on 4 June 2026.
  4. September: submit applications. For the 2027 cycle, applicants could submit from 2 September 2026 and programs could review from 23 September 2026, according to the AAMC.
  5. By the Rank Order List deadline: the NRMP requires IMGs to have met all ECFMG exam requirements by this date, which is 3 March 2027 for the 2027 Match.
  6. Before residency starts: hold a valid ECFMG Certificate, which requires your final medical diploma.

Our guide to the residency Match for international medical graduates covers the Match itself and recent IMG match rates.

Choosing a school with the USMLE in mind

If you have not yet chosen where to study, check the school's World Directory listing and its accreditor's recognition before you enroll. Our programs directory lists accreditation and US licensing notes for each school, and our guide on how graduates of international medical schools find employment explains what happens after training.

Key takeaways

  • IMGs need USMLE Step 1 and Step 2 CK, a completed ECFMG Pathway with an OET Medicine score, and verified credentials for ECFMG Certification.
  • Step 1 has been pass/fail since January 2022; Step 2 CK's minimum passing score has been 218 since July 2025.
  • Step 3 is open to IMGs only after graduation and ECFMG Certification, and most take it during residency.
  • Four or more failed attempts at any Step end your USMLE eligibility.
  • Intealth's Recognized Accreditation Policy, implemented in November 2024, accepts WFME or NCFMEA recognition but does not currently block individual certification.
  • For the 2027 Match, Pathway applications and OET scores are due to ECFMG by 31 January 2027, and exam requirements must be met by 3 March 2027.