The Path to Board Certification for International Medical Graduates (IMGs)
An International Medical Graduate (IMG) is a physician seeking to enter the U.S. healthcare system after graduating from a medical school outside the United States, including American citizens who attended schools outside the US. IMGs face several hurdles to practicing medicine in the U.S., including licensure and board certification. For most foreign graduates, board certification requires an American post-graduate program, typically an ACGME-accredited residency, and passing the relevant board exam for your specialty.
ECFMG Certification
All international medical graduates—including U.S. citizens who graduated from non-U.S. medical schools—must obtain Educational Commission for Foreign Medical Graduates (ECFMG) certification before entering an ACGME-accredited U.S. residency or fellowship program.
The Educational Commission for Foreign Medical Graduates (ECFMG) verifies the medical education credentials of IMGs and determines eligibility for U.S. graduate medical education. ECFMG certification confirms that an IMG has met the educational, examination, and English-language proficiency requirements necessary to enter U.S. residency or fellowship training.
To obtain ECFMG certification, IMGs must:
- Graduate from an eligible medical school
- Pass USMLE Step 1 and Step 2 CK
- Meet ECFMG’s English-language proficiency requirements (currently through designated ECFMG Pathways)
USMLE Step 3 is not required for ECFMG certification but is typically required for state medical licensure.
Verification of Foreign Medical Schools
To be eligible for ECFMG certification, your medical school must be listed in the World Directory of Medical Schools and include an ECFMG sponsor note indicating eligibility. There will be a sponsor note section for each medical school, and eligible international schools will have a sponsor note from the ECFMG. If your school does not have a sponsor note from ECFMG, you will not meet the eligibility requirements.
You must also pass Steps 1 and 2 of the United States Medical Licensing Examination (USMLE). You will need an offer of employment or residency offer and a federal immigration status to practice as a physician in the US. Eligibility for Step 3 is determined by FSMB and state medical boards. Most states require ECFMG certification, but ECFMG itself does not grant Step 3 eligibility.
The United States Medical Licensure Exam (USMLE)
The USMLE (United States Medical Licensing Examination) is a three-part exam (Steps 1, 2 CK, & 3) by the National Board of Medical Examiners (NBME) and the Federation of State Medical Boards (FSMB).
Passing all 3 Step exams is required for medical licensure. Step 1 tests foundational sciences, and Step 2 CK focuses on clinical application. These two exams are often taken during medical school. Step 3 is often taken during residency, but many IMGs take it before residency. It has a primarily clinical focus.
Alternate Pathways to Licensure and Board Certification in Exceptional Circumstances
Alternative pathways are primarily intended for experienced, licensed physicians who have completed postgraduate medical training outside the United States. These pathways are generally not available to early-career or unlicensed graduates. In limited circumstances, there are pilot programs, such as the American Board of Internal Medicine Pilot Pathway E, that offer alternative pathways for IMGs with extensive residency experience abroad, in addition to a US fellowship or research program, to become eligible for board certification without completing a full US residency. Some specialty boards will allow IMGs who have completed a US clinical fellowship and an overseas residency to apply for certification. These requirements may include research and clinical practice. Most alternative state licensure pathways do not automatically confer eligibility for ABMS board certification. Board certification requirements are determined independently by each specialty board.
There are programs in 12 states that offer a path to licensure for internationally trained physicians (ITP), which refers to doctors who hold licensure and have practiced medicine outside the US and completed postgraduate medical training. These programs vary by state in terms of structure and eligibility requirements.
These pathways to licensure programs are meant to address healthcare workforce shortages in these states, typically in underserved or rural areas. States with an alternative licensure pathway include Arkansas, Florida, Iowa, Idaho, Illinois, Indiana, Louisiana, Massachusetts, Oklahoma, Tennessee, Virginia, and Wisconsin. Over 20 additional states have considered or introduced legislation to offer alternative licensure pathways for ITPs. These programs are evolving rapidly, and eligibility criteria vary significantly by state.
The Occupational English Test (OET)
The Occupational English Test, (OET) is an English language proficiency exam designed for international healthcare professionals who want to work or study in English-speaking countries. The OET content tests English for twelve different healthcare professions.
It assesses communication skills in four areas: Listening, Reading, Writing, and Speaking, using area-specific scenarios to ensure IMGs can practice safely and effectively. The results are given as grades A (highest) to E (lowest) for each sub-test, although an overall score is not provided.
The ECFMG also manages J-1 sponsorships for foreign doctors entering residency or fellowship programs in the United States.
A Checklist for IMGs Seeking Board Certification
- Identify your specialty’s certifying board via the American Board of Medical Specialties (ABMS).
- Begin with ECFMG certification and create a MyIntealth account.
- Prepare for and pass USMLE Step 1 and Step 2 CK.
- Meet English-language and visa requirements.
- Research and apply to ACGME-accredited U.S. residency programs.
- Complete the required residency training.
- Take USMLE Step 3, as required for state licensure.
- Apply for state medical licensure.
- Apply for and pass your specialty board examination(s).
Final Thoughts on Board Certification for International Medical Graduates
In most cases, if you are an international medical school graduate seeking board certification in a residency in the United States, the ECFMG portal is the best place to start. Alternative pathways are generally intended for experienced physicians who have completed postgraduate medical education and practiced independently outside the United States. These pathways are not designed for early-career or unlicensed graduates. Pathways are also available for licensure for experienced physicians or academicians, who usually enter under an “eminence” or O-1 visa designated for those with extraordinary ability. Still, in most cases, these doctors have already completed graduate medical education in their own countries. IMGs are strongly encouraged to verify requirements with ECFMG, state medical boards, and specialty certifying boards, as policies evolve regularly.