Mandatory Exams for IMGs Only: OET Medicine and the Clinical Skills Evaluation (Pathways)

International medical graduates (IMGs) must meet two requirements that U.S. and Canadian medical school students do not: a communication-skills requirement, met with the Occupational English Test (OET) Medicine, and a clinical-skills requirement, met through an ECFMG Pathway. Both are part of ECFMG Certification, which sits alongside the USMLE examinations and verification of your medical diploma. Since the in-person USMLE Step 2 CS exam was discontinued, these two requirements replace it. This article explains what each one is, how they fit together, and what to confirm before you register.

OET Medicine (Occupational English Test)

OET Medicine assesses the English you need in a clinical setting, such as reading a referral, listening to a consultation, writing a letter to another clinician and role-playing a conversation with a patient. ECFMG uses it to satisfy the communication-skills requirement, and, for applicants who use the Pathways, it applies to everyone regardless of native language, language of instruction or citizenship.

OET Medicine at a glance, as published by ECFMG.
Item	What to know
Sub-tests	Listening, Reading, Writing and Speaking.
Minimum scores	350 on Listening, Reading and Speaking, and 300 on Writing.
One sitting	All four minimum scores must come from a single test administration. ECFMG does not combine results from different dates.
Retakes	If you miss any minimum, you retake all four sub-tests and must reach every minimum in one administration. There is no limit on the number of attempts, subject to test availability.
Test formats	Paper-based and computer-based at test venues worldwide, and OET@Home with remote proctoring for applicants who have no test venue in their country.
Test date recency	ECFMG only accepts results from tests taken on or after a cutoff date that changes each application cycle.

Preparing for OET Medicine

It is not a multiple-choice exam. Writing and Speaking are scored on clinical communication, so practice with timed writing tasks and recorded role-plays.
Even fluent speakers should prepare. The test rewards structure, clarity and professional tone, not just vocabulary.
Book early. Test dates and venues can fill, and your scores need to reach ECFMG before your Pathways application is complete.

Clinical Skills Evaluation (Pathways)

The Pathways let ECFMG confirm your clinical skills by using evaluations from your medical school or licensing history in place of a single national exam. You apply to the one Pathway that fits your situation. A passing performance on the former Step 2 CS also continues to count where it is still valid for ECFMG Certification.

The six Pathways, in the order ECFMG lists them.
Pathway	Who it is for	How clinical skills are shown
1	You hold, or recently held, a license to practice medicine without supervision, with no disciplinary action.	Your license history, verified by ECFMG.
2	You do not qualify for Pathway 1, and your medical school completes an Objective Structured Clinical Examination (OSCE).	An OSCE attestation from your medical school, or primary-source verification of your final diploma if it has already been issued.
3	Your medical school is accredited by an agency recognized by the World Federation for Medical Education (WFME).	A clinical skills attestation from your school, based on faculty assessment of three in-person patient encounters.
4	Your medical school is accredited by an agency determined comparable by the National Committee on Foreign Medical Education and Accreditation (NCFMEA).	The same clinical skills attestation as Pathway 3.
5	Your school grants an MD degree jointly with a U.S. medical school accredited by the Liaison Committee on Medical Education (LCME).	The same clinical skills attestation as Pathway 3.
6	You do not meet the requirements for Pathways 1 to 5.	Six real, in-person encounters observed by licensed physicians using ECFMG's Mini-Clinical Evaluation Exercise (Mini-CEX). You need an acceptable score in each of four areas, for all six encounters: medical interviewing, physical examination, professionalism and communication, and clinical reasoning and judgment.

For Pathways 3, 4 and 5, each of the three encounters lasts 10 to 20 minutes, and at least one is on the general medical hospital service.

How the pieces fit together

Choose your Pathway. Work through the list in order and use the first one that applies. Check your medical school's accreditation status in the official directories before you decide.
Book and take OET Medicine. Plan the date so results arrive before your Pathways application deadline.
Arrange the school or physician evaluations. Some Pathways depend on your medical school completing an attestation or on supervising physicians completing Mini-CEX forms. Start these conversations early, because other people control the timing.
Apply and track your status. ECFMG reviews the evidence and updates your certification record.
Keep the USMLE steps on schedule. OET and the Pathways run in parallel with Step 1 and Step 2 CK, and all of it must be complete before you can be certified.

Common mistakes

Combining OET results from different test dates. ECFMG does not accept this.
Waiting until the last test date. A retake after a near miss may not return results in time for the Match.
Assuming your school will complete an attestation without asking. Request it early and confirm it was submitted.
Using an outdated Pathways list. Requirements are published per cycle and can change.

Confirm the current rules

Deadlines, fees, test-date cutoffs and eligibility are published for each application cycle. Read the current requirements on the ECFMG Pathways pages and the OET page for ECFMG applicants before you register. This article is general educational information, not advice on your individual eligibility. See also our exam guides for the USMLE steps.

Educational content only. Confirm current exam requirements with USMLE.