How to Become a Licensed Physician in the United States (Updated 2025)

International medical graduates (IMGs) and U.S. medical graduates frequently contact our office to inquire about the steps necessary to becoming a licensed physician in the United States. The pathway is rigorous and often complex—especially for IMGs—but having clarity on the latest rules and practices can make a huge difference. Below is an updated guide, reflecting the changes as of mid-2025.

Key Organizations and Terminology

• ECFMG (Educational Commission for Foreign Medical Graduates): Certifies IMGs, verifies credentials, and ensures eligibility to enter U.S. graduate medical training.
• USMLE (United States Medical Licensing Examination): Three-step exam series required generally for medical licensure.
• ACGME (Accreditation Council for Graduate Medical Education): Accredits U.S. residency and fellowship training programs.
• FSMB (Federation of State Medical Boards): Sets standards and works with state licensing boards.

Updated Steps & Requirements

Here’s what’s required, as of 2025, for IMGs seeking licensure in the U.S.:

1. Medical School Graduation and School Eligibility
   • Your medical school must be listed in the World Directory of Medical Schools with an “ECFMG Sponsor Note” indicating it meets the eligibility criteria for graduates and students to apply for ECFMG Certification.
   • From July 1, 2025, graduates of Canadian medical schools graduating on or after that date are automatically considered IMGs for purposes of residency application/licensure, which means they must get ECFMG Certification.
2. ECFMG Certification

Before entering a U.S. residency, IMGs must obtain ECFMG Certification. The certification process includes:

1. • Passing USMLE Step 1 and USMLE Step 2 Clinical Knowledge (CK).
   • Satisfying the clinical skills requirement and English/communication skills requirement. Since the discontinuation of USMLE Step 2 Clinical Skills (CS), these are now met through ECFMG’s Pathways system.
   • Completing the required medical education credentials, with primary source verification of transcripts and diplomas.
   • Using MyIntealth, ECFMG’s online portal, to apply and track certification.
2. Matching into a Residency Program (Graduate Medical Education, GME)
   • All prospective residents (IMGs or US grads) apply through ERAS (Electronic Residency Application Service).
   • The NRMP Match (National Resident Matching Program) determines placement. To participate in the Match, IMGs must have met the examination and pathway requirements by the deadline (NRMP’s Rank Order List certification deadline).
3. Residency Training
   • You must complete a residency program accredited by ACGME. The number of years depends on specialty (e.g. at least 3 years for many primary care specialties). American Medical Association
   • Some U.S. states are now relaxing or changing rules about requiring IMGs to repeat residency if they have already completed one abroad. These changes are recent, variable by state, and often apply only in certain circumstances. Stateline
4. State Medical License
   • After finishing residency, you apply for a medical license in the U.S. state(s) where you plan to practice. Each state board sets its own requirements. These typically include proof of medical education, residency completion, passing USMLE steps, verification of credentials, background checks, etc. American Medical Association
   • Many states use the FSMB’s Federation Credentials Verification Service (FCVS) or other credential verification systems. Primary source verification is essential.

Recent Changes & Important Updates (2023-2025)

To stay current, here are some of the most significant changes:

• USMLE Service Functions Centralization: Starting mid-2025, the FSMB will take over many USMLE service functions (for Step 1, Step 2 CK, Step 3) including registration, score reporting, eligibility, etc., for IMGs; USMGs will continue to work with NBME for some parts.
• Pathways Model for Clinical & Communication Skills: Since the discontinuation of USMLE Step 2 CS, ECFMG now uses a Pathways model to satisfy clinical/communication skills requirements.
• Expiration of Pathways / ECFMG Certificate Validity: Pathways have seasons, and accepted Pathways can expire. If a Pathway expires, the ECFMG certificate may no longer be valid for matching or residency or for USMLE Step 3 unless revalidated or made permanent (by doing certain clinical training in the U.S., or holding a license).
• Canadian Graduates as IMGs: As noted, Canadian medical graduates with graduation dates on or after July 1, 2025 are treated as IMGs for certification/licensure/residency-application purposes.
• State-Level Licensing Flexibilities: Because of doctor shortages, several states have changed laws to allow foreign-trained physicians to get licenses without repeating U.S. residency in some cases. The specifics vary by state.

Challenges and Tips

While the pathway is clearer for many, there remain pitfalls and areas where people often get stuck. Here are some practical suggestions:

• Check eligibility early: Confirm your medical school has the required ECFMG Sponsor Note and that your graduation date is acceptable. Delays in transcript verification or diploma issue are common.
• Understand deadlines: The NRMP Match, Pathways acceptance, and expiration deadlines are strict. Missing one can cost you a year.
• Plan the USMLE steps well: Since some services and registration functions are shifting, make sure you use the correct registration body and understand the policies for prorated or delayed score reporting etc.
• Monitor state boards’ requirements: Each state has its own licensing rules; some states have recently changed laws for IMGs. Be sure to check the exact requirements for where you intend to practice.
• Maintain valid credential verification: Using FCVS or equivalent services helps, but ensure that all primary source documents are acceptable and translated if needed.

Summary

Becoming a licensed physician in the U.S. remains a multi-step process involving:

1. Graduation from an eligible medical school.
2. ECFMG Certification (exams + credential verification + clinical/communication skills pathway).
3. Applying through ERAS and Matching via NRMP.
4. Completion of residency training (ACGME-accredited).
5. Obtaining state licensure, which varies by state but requires verification of credentials and often background checks.

While many foundational components remain unchanged, recent shifts (e.g. U.SMLE service centralization, expiration of Pathways, Canadian grads as IMGs, state flexibility) mean that aspiring physicians should stay up to date by consulting official sources like ECFMG, USMLE, FSMB, and relevant state medical boards.

The attorneys at Abramson & Abramson have:

• Successfully defended examinees against allegations of irregular behavior brought by USMLE.
• Successfully defended IMGs against allegations of irregular behavior brought by ECFMG.
• Successfully defeated the attempts of GME residency training programs to obtain a waiver from a match commitment with NRMP, resulting in NRMP’s refusal to grant the waiver, thus requiring the residency program to fulfill its match commitment and employee and train the client.
• Successfully obtained match commitment waivers sought by our clients from NRMP.
• Successfully obtained exceptions to ECFMG credentialing rules and policies, including with respect to primary source verification and the “Seven Year Rule”, thus permitting our clients to obtain and/or otherwise be eligible for ECFMG Certification
• Successfully obtained state medical board sponsorship to permit our clients additional attempts on USMLE Step examinations beyond the “Four Attempt Rule”
• Successfully caused institutions to modify client reports previously made to the National Practitioner Data Bank (NPDB or the Data Bank)
• Successfully caused institutions to modify reports previously made and which previously appeared on the client’s FCVS Report
• Successfully defended disciplinary actions brought by FSMB-member state medical boards against our physician clients’ licenses
• Successfully defended claims of irregular conduct by the National Board of Osteopathic Medicine (NBOME)
• Successfully defended claims brought by the American Board of Internal Medicine (ABIM) that clients had unauthorized access to ABIM Board Certification examination content in advance of examination
• Successfully applied for additional years of Board Eligibility to various specialties boards, including the American Board of Internal Medicine (ABIM).
• On more than one occasion, successfully caused our client’s ECFMG Certificates to be reinstated after revocation
• Successfully defended allegations brought by AAMC for failure to provide truthful and complete information on an ERAS application, resulting in no finding of a violation of the ERAS Integrity Policy.

Should you have a question about the process of becoming a physician or with respect to any credentialing or licensing body’s rules, policies, and procedures, or otherwise require legal assistance in related matters, our experienced attorneys stand ready to assist.

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