Foreign medical graduates seeking to practice clinical medicine in the U.S. usually must complete (or in some cases repeat) residency training at a U.S. program in order to obtain a state medical license. Doctors who have completed an accredited residency training program in Canada are often exempt from this requirement and may obtain a state license without repeating residency training in the U.S. To obtain U.S. residency program placement, a foreign medical graduate must successfully complete an English test and a basic science test and receive certification through the Educational Commission for Foreign Medical Graduates (ECFMG) of their foreign education. ECFMG can act as a visa sponsor enabling the foreign medical graduate to obtain a J-1 visa and enroll in the residency program. Alternatively, the residency program itself may sponsor the foreign medical graduate for an H-1B visa
I. Steps to obtain a US residency:

• Choose desired residency.
• Obtain an ERAS from the Electronic Residency Application System
• Send ERAS application to ECFMG.
• Register with the National Residency Matching Program as an independent application.
• Check status of ERAS submission by viewing the Automated Document Tracking Systems (ADTS).
• Contact hospitals that have received ERAS application, and inquire about interviews.
• Attend interviews and rank most desired programs. Be sure to inquire at residency interviews if the hospital is willing to sponsor for an H-1B visa.
• Submit rank order to the National Residency Matching Program.
• Consult with an attorney regarding visa options and consider obtaining licensing application materials for the states will likely match with.
• Sign residency contract, and initiate the licensing procedure for the state in which matched. Please note that not all states require medical licenses for residents.
• Immediately initiate immigration processes to obtain the necessary non-immigrant visa (J-1 or H-1).

II. Credentialing and Licensing
Credentialing is a term that refers to the substantive requirements imposed on doctors by U.S. immigration law. Licensing refers to the requirements imposed by various States in the U.S. as a prerequisite to the practice of medicine. Most foreign medical graduates coming to perform patient care must satisfy special requirements for immigration status and state licensing. While the immigration and licensing prerequisites for foreign medical graduates have been streamlined in recent years, the framework is still complex, and each option needs to be carefully examined before any is pursued.
With the introduction of the United States Medical Licensing Examination (USMLE), previous credentialing exams such as the National Board of Medical Examiners Examination (NBME), the Foreign Medical Graduate Examination in the Medical Sciences (FMGEMS), the Visa Qualifying Examination (VQE), and the Federal Licensing Examination (FLEX) have been replaced. The USMLE is composed of three steps (USMLE Step 1, 2 and 3). USMLE steps I and II are deemed equivalent to NBME Parts I and II, to the VQE, and to the FMGEMS. USMLE Steps 1, 2 and 3 are deemed equivalent to NBME Parts I, II, and III, and to the FLEX. By 1995, the USMLE fully replaced all of the previous credentialing exams listed above, although results from the prior examination remain valid. The consolidation of examinations into the USMLE should help foreign physicians, who will no longer have to take a lower level examination series for immigration purposes and the FLEX for licensing.

Combinations of various steps from different exams may, in certain circumstances, be effective and are further described in the USMLE booklet. Keep in mind, though, for H-1B purposes, combinations of the components of the three applicable examinations (such as USMLE Parts 1 and 2, and Flex Part 2) are not sufficient.
The United States Medical Licensing Examination (USMLE) is comprised of three steps (Step 1, 2 and 3). Each step is composed of multiple choice questions, requiring two days of testing, and is administered twice annually. Step 2 may be taken before Step 1. The ECFMG administers the USMLE Steps 1 and 2, but Step 3 is only administered by the state licensing boards of the U.S. A growing number of state boards administer Step 3 to foreign doctors who have not yet completed the residency requirements for state licensing. A booklet is available directly from the National Board of Medical Examiners or ECFMG that further explains the USMLE.
To be eligible for Step 1 or Step 2 of the USMLE, generally speaking, an individual must be a medical student officially enrolled in, or a graduate of, a U.S. of foreign medical school. To be eligible for Step 3, prior to submitting the application, an individual must:

• Meet the Step 3 requirements as a set by the medical licensing authority to which he/she has applied;
• Obtain the MD degree (or its equivalent);
• Obtain passing scores on USMLE Step 1 and 2; and
• Obtain certification from the ECMFG or successfully complete a 'Fifth Pathway' program if he/she is a graduate of a foreign medical school.

The ECFMG </SPAN>English test is a one-hour test usually administered in the morning before the second day of a USMLE Step 2 testing. It is required for many non-immigrant and immigrant visas for physicians.
None of the previously mentioned credentials automatically entitles one to a medical license in the U.S. The individual U.S. state licensing boards impose additional requirements, such as residency/training programs as a pre-requisite for licensing in the respective state. Sometimes, more training is required for licensing of foreign graduates than for U.S. graduates. However, some U.S. states give credit to foreign physicians who have prior training in England or Canada.
A. Medical Research Only
The previous discussion on credentialing, licensure, and further immigration related requirements aimed at physicians do not apply if the foreign physician is coming to the U.S. to engage in any other type of work other than patient care or in work in which patient care is only incidental, such as observation, teaching, or research.
B. What are the requirements for licensure in a particular U.S. state?
Each U.S. State has a medical board which formulates its own requirements and procedures for licensing for those practicing medicine in the state. With that said, however, most if not all, states require and recognize USMLE. Additional information about individual state licensing requirements should be addressed to the medical board of your intended state of employment
C. ECFMG Certificate
The Educational Commission for Foreign Medical Graduates (ECFMG) Certificate is a document proving that an individual has fulfilled the education requirements needed to practice medicine in the U.S. To obtain the ECFMG Certificate, an individual must:
1. Have had his/her medical degree certified by ECMFG;
2. Passed the USMLE Step 1;
3. Passed the USMEL Step 2CK; and
4. Passed the USMLE Step 2CS (formerly the Clinical Skills Assessment).
Once achieved, the ECFMG will issue a certificate which verifies that the individual has fulfilled the requirements to enter medical training in the U.S. The ECFMG certificate must be valid when the foreign medical graduate applies for a visa or starts his/her training.
The USMLE Step 2CS examination is now being held in Los Angeles, Houston, Atlanta, Chicago and Philadelphia throughout the year. Individuals are tested on their ability to rapidly assess a patient, communicate their thoughts to them, and to write a note about their assessment and plans. Application is through the ECFMG only

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