A clearer path for international medical graduates
Understand where ECFMG Certification, USMLE registration, residency, and immigration status fit together.
ECFMG Certification
ECFMG Certification evaluates whether international medical graduates are ready to enter accredited U.S. graduate medical education. IMG status is based primarily on where the medical degree was earned, not citizenship. Your school and graduation year must meet the applicable World Directory and ECFMG eligibility requirements.
Certification includes medical-science examination requirements, clinical and communication skills requirements through the applicable Pathway, and primary-source verification of medical credentials. Since the 2026 USMLE service transition, eligible students and graduates of medical schools outside the United States register for Step exams through FSMB, while ECFMG continues to determine Certification eligibility.
What certification requires
| Requirement | What it means |
|---|---|
| An eligible medical school | Your school must be listed in the World Directory of Medical Schools with a graduation year that meets ECFMG's eligibility rules for your graduation date. |
| Verified medical credentials | ECFMG verifies your diploma and transcripts directly with your school (primary-source verification) through your MyIntealth account. |
| Medical science examinations | You must pass USMLE Step 1 and Step 2 CK within ECFMG's time limit for completing the examinations. |
| Clinical and communication skills | You meet this through one of ECFMG's six Pathways, which includes a satisfactory score on OET Medicine. A valid pass on the former Step 2 CS also counts. See our guide to OET Medicine and the Pathways. |
The usual order of steps
- Confirm that your school and graduation year are eligible, and create your ECFMG/MyIntealth account.
- Submit your medical credentials for verification. This can take weeks because your school must respond, so start early.
- Register for and pass Step 1 and Step 2 CK, using the registration process described below. Plan Step 3 as well, since many programs ask for it before they will sponsor a visa. See our Step 1, Step 2 CK and Step 3 preparation plans.
- Take OET Medicine and apply to the Pathway that fits you.
- When all requirements are met, ECFMG issues the certificate. You need to be certified by the deadline that applies to the Match you are entering.
- Apply to programs and rank them. The program you match with then arranges your visa sponsorship, if you need one.
Visa pathways in plain language
J-1 physician status
ECFMG is the designated sponsor for foreign national physicians in U.S. clinical graduate medical education. The training institution and its liaison coordinate with ECFMG, which determines sponsorship eligibility and issues Form DS-2019. Physicians in J-1 status for graduate medical education are subject to the two-year home-country physical presence requirement unless a waiver is granted.
H-1B status
H-1B is an employer-petitioned temporary worker category. A residency or fellowship program must be willing and able to file the petition, and institutional rules, licensing, examination, and federal requirements apply. Availability varies by program and by individual circumstances.
Visa rules are legal matters and can change. Confirm details with the training program, ECFMG/Intealth, the U.S. Department of State, USCIS, and qualified immigration counsel. This guide is general education, not legal advice.
Visa options compared
| Status | Who sponsors | What to know |
|---|---|---|
| J-1 physician (exchange visitor) | ECFMG, at the request of the training program. | The most common route for residency and fellowship. ECFMG issues Form DS-2019 once the program and your certification are in order. It is tied to your training program and usually carries the two-year home-country physical presence requirement, which can be waived only through specific waiver programs. |
| H-1B (temporary worker) | The employer (the training program or sponsoring institution) files the petition. | Not every program sponsors it. Programs that do often require that you have passed Step 3 first, and must meet state licensing and institutional rules. H-1B filing costs and rules have been the subject of recent federal action and litigation, including a large new fee proposed in 2025 and debate over exemptions for physicians, so ask the program what applies to you now. |
| Permanent resident or citizen | None needed. | You are treated like a U.S. applicant for work authorization. You are still an IMG for ECFMG Certification if you graduated from a medical school outside the U.S. and Canada. |
| Other work-authorized status | Depends on the status. | Some applicants already hold work authorization through another status, for example as a refugee or asylee, or through a family member. Confirm with the program that your document is accepted for employment in training. |
| Visitor, student and TN statuses | Not for residency. | A B-1 or B-2 visitor visa does not allow paid work or patient care, so it is not a way to train. The TN category for Canadian and Mexican citizens covers physicians only for teaching or research, not clinical practice, so it does not usually cover residency. |
Questions to ask programs
- Which visa types do you sponsor: J-1, H-1B, or both?
- Do you require Step 3 before H-1B sponsorship, and by what date?
- How are visa costs handled, and who pays?
- How do you handle the start date if my visa processing is delayed?
Many programs state their visa policy in their FREIDA listing and on their own websites. Check it before you apply, and ask the program coordinator if it is unclear.