Working As A Physician in the United States

Medical licensure for Foreign Medical Graduates (FMG) in the United States is completed through the Educational Commission for Foreign Medical Graduates (ECFMG), http://www.ecfmg.org/. The licensure process is a lengthy process and the time to completion varies from individual to individual. There are eight major steps typically involved in acquiring licensure. It is highly recommended you visit ECFMG’s website and talk to medical professionals for more information.

Step I: Confirm eligibility with ECFMG

To begin, check the World Directory of Medical Schools, http://wdoms.org, to ensure that your school is listed. This is necessary to ensure that you qualify to take the licensure examination (United States Medical Licensure Examination, USMLE). Be sure to read the notes and check the graduation years under the “Sponsor Notes” tab when you find your university. Note that requirements for current medical students differ in terms of eligibility.

Step II: Acquire an ECFMG/USMLE Identification Number

An Educational Commission for Foreign Medical Graduates (ECFMG)/ United States Medical Licensure Examination (USMLE) Identification Number is required before applying for ECFMG certification or taking the USMLE. The Identification Number is acquired online: https://secure2.ecfmg.org/usmleidrequest/usmleidrequestnavigator.aspx. The identification number takes about five business days to process and is sent via e-mail. It is very important to enter your name and information in full, exactly as it appears in your official identification document (passport). This becomes part of your official record and the number will be used throughout the examination and licensure process.

Step III: Apply for ECFMG Certification

You are required to apply for certification from the ECFMG before taking the USMLE. Certification from the ECFMG is necessary because it helps determine whether graduates from institutions outside of the US or Canada are prepared to work in residency programs accredited by the Accreditation Council for Graduate Medical Education or ACGME, http://www.acgme.org/. The ACGME requires this certification for FMGs to be able to enter residency programs. ECFMG Certification is also required for taking Step 3 of the USMLE (see below). Application for ECFMG Certification costs $75.00 and can be found online.

Step IV: Apply and Register for USMLE Step 1, Step 2 CK and Step 2 CS

You are required to take all three steps of the USMLE and pass the exam to be able to practice as a physician in the United States. You must take Steps 1, Step 2 Clinical Knowledge (CK), and Step 2 Clinical Skills (CS) before taking Step 3; however, you can take these first three steps in any order. Note that the exams can be re-taken three times within a 12-month period, but you cannot re-take a step if you have already made six attempts. In addition, eligibility for licensure in some states, including Texas, requires that candidates do not exceed a certain number of exam attempts.

To apply and register to take the exam, you must complete an online and paper application. For the online portion, you are required to have an e-mail address, your ECFMG/USMLE Identification Number and login and a payment method. Upon completion of the online application, you are provided with the paper portion of the application, which consists of a Certification of Identification Form (Form 186) or Certification Statement Form (Form 183). You are required to fill out one of these forms and have it certified by the Dean, Vice Dean or Registrar of your university. If this is not possible, then you must sign the form in front of a public notary, consular official, or first class magistrate here in the US.

Along with this application, you must submit a passport-sized photo, two photocopies of your medical diploma, transcripts, and if applicable, transfer credit transcripts to the ECFMG. ECFMG verifies the documents with an authorized official from your school. Documents should be in English or translated to English. The ECFMG recommends using Straker Translations, https://www.strakertranslations.com/ecfmg/, which can be completed online. Fees vary according to number of pages and content. Note that if you use another service and translation is deemed insufficient by the ECFMG, the ECFMG will have the documents translated for $250.00.

Step 1 of the USMLE tests general scientific knowledge of organ systems with respect to their application to the medical field. The exam duration is 8 hours and is taken in one sitting, while the format is multiple choice. Step 2 CK of the examination is also multiple choice and focuses on the application of medical knowledge to patient care. The exam duration is 9 hours and likewise, taken in one sitting. For Step 2 CS of the exam, you are required to meet with 12 patients for 15 minutes each. This portion of the exam tests doctor capabilities to collect patient history and information about medical cases, conduct basic exams, and communicate medical knowledge to patients under supervision. For more information about test content, visit USMLE’s website, http://www.USMLE.org.

Downloadable practice materials are available on the USMLE website: http://www.usmle.org/practice-materials/index.html. The National Board of Medical Examiners (NBME) also offers self-assessments for $50.00 each (standard feedback) or $60.00 (expanded feedback). More information can be found on NBME’s website, https://nsas.nbme.org/home. Finally, practice sessions are offered by USMLE at Prometric Testing Centers and are available after you register for Step 1, Step 2 CK or Step 3. Steps 1 and 2 practice session costs $75 and take 3.5 hours, while step 3 costs $77 and takes 4 hours.

Application and Registration for Steps 1, 2 CK and 2 CS is completed through the ECFMG as well, https://secure2.ecfmg.org/emain.asp?app=iwa. For Step 1 and Step 2 CK, you will need to sign-up for a three-month eligibility period for taking the exam. For Step 2 CS, you are given a 12-month eligibility period for taking the exam and you will receive a scheduling permit. After applying, you will be required to register for a test date on Prometric, https://www.prometric.com/en-us/clients/usmle/Pages/landing.aspx, for Step 1 and Step 2 CK or the ECFMG website for Step 2 CS, https://secure2.ecfmg.org/emain.asp?app=csess. The costs for taking the exams are $895.00 for Step 1, $895.00 for Step 2 CK, and $1,550.00 for Step 2 CS.

Step V: Receive ECFMG Certification

You will receive ECFMG Certification once you successfully pass USMLE Step 1, Step 2 CK, and Step 2 CS of the USMLE and your credentials are verified.

Step VI: Apply for GME Programs

You are required to complete a Graduate Medical Education (GME) or residency program upon receiving your ECFMG Certification. Programs typically last a minimum of three years and involve several requirements. Applications can be submitted through the Electronic Residency Application Service (ERAS). For more information, visit https://www.aamc.org/services/eras/. Also refer to http://www.ecfmg.org/eras/schools-overview.html for ECFMG information and support. Check ERAS for fees and schedules. You must register with the National Resident Matching Program (NRMP), which matches applicants to open programs, http://www.nrmp.org/.

Step VII: Apply for and pass USMLE Step 3

Step 3 is the final step in the USMLE and may be taken during the GME. This step ensures doctors can apply their medical knowledge without supervision in a clinical setting. This examination is used to determine whether doctors are ready to receive their license to practice medicine. The exam takes place over the course of two days, with the first day, called Foundations of Independent Practice (FIP), taking about 7 hours, and the second day, called the Advanced Clinical Medicine (ACM) taking around 9 hours. The exam includes 233 multiple choice questions and 13 case simulations.

Registration is completed through the Federation of State Medical Boards (FSMB), http://www.fsmb.org/licensure/usmle-step-3/ and applicants are required to sign- sign-up for a three-month eligibility period and select a date through Prometric, https://www.prometric.com/en-us/clients/usmle/Pages/landing.aspx. The cost of Step 3 is $845.00. 

Step VIII: Apply for State Licensure

After successfully passing Step 3 of the USMLE, you are eligible to apply for state medical board licensure. This process may differ from state to state and it is completed by the Texas Medical Board (TMB) here in Texas. It is highly recommended that you check TMB’s website, http://www.tmb.state.tx.us/, for the most updated information.

To apply, you are required to possess a degree from outside of the US or Canada and ensure that your school is on the Substantial Equivalency List: http://www.tmb.state.tx.us/idl/A9AFA127-082F-6C6D-1421-B5BEDB9C3E02. Additionally, you must have completed a GME program for at least 2 years in the US or Canada. Finally, you are required to pass the Texas Medical Jurisprudence Examination with a score of at least 75. Practice materials are available on the TMB’s website and doctors can register for the examination at http://www.pearsonvue.com/tx/medicalboard/. The cost of the exam is $61.00.

The licensure process includes screening and applying. After uploading all your documents to the online portal (called Licensure Inquiry System of Texas, LIST), you will be notified of any missing documents. The current cost for the application is $817.00, with additional fees for initial registration and other requirements. The TMB is required to process all applications within 51 days.