International Medical Graduates (IMG) toolkit: State medical licensure

State licensure requirements are designed to provide that graduates of foreign medical schools meet the same requirements to obtain a medical license as graduates of an accredited United States or Canadian medical schools.

The Federation of State Medical Boards (FSMB) offers a reference on the pathway to medical licensure in the U.S. and related definitions (PDF). Visit the FSMB state licensure page to find specific licensure requirements by state.

Many international medical graduate (IMG) physicians believe that once they pass the Educational Commission for Foreign Medical Graduates (ECFMG) exams and obtain a residency in the U.S. they automatically receive a license to practice medicine in any state in the U.S. While that is true for the vast majority of physicians, there are many nuances and other issues which will determine the availability of an unlimited license to practice medicine in the U.S.

All state licensing jurisdictions require a graduate of a foreign medical school to complete at least one year of accredited U.S. or Canadian graduate medical education before licensure.

However, 12 states require two years and 25 states require three years of accredited graduate medical education, so it is important for IMGs to verify licensure requirements for each state.

United States medical licenses are governed by individual state laws and regulations. Every medical graduate must apply for a license in the state(s) in which they intend to practice. Though there are 50 states, there are about 70 separate jurisdictions that come into play. This is created because some states have separate boards for MD and DO licensure and others have a common board for both.

It is better to know state requirements and which board to apply to prevent delays in obtaining a license.

Each state has its own requirements and processes for application and a separate dues structure.

Physicians looking to relocate should contact the licensing board of the state they are moving to and ask for a copy of its current licensing requirements and the time it takes to process a licensure application. This will provide the physician with a time frame of when to consider closing an existing practice and help planning a move.

While licensure requirements for domestic and international medical graduates differ between the states, all states require proof of education, training and licensure exam completion. Additionally, though there has been some commonality in applications through the Federation Credentials Verification Service (FCVS) created by the Federation of State Medical Boards (FSMB), all states consider the following:

Seven- or 10-year rules

All states have the requirement that applicants must have passed all three parts of the United States Medical Licensing Examination (USMLE) exams within a span of seven to ten years. This is counted from the first time when an applicant takes the USMLE Step 1 examination.

Some exemptions apply to applicants who have done dual degrees like MD/PhD or MD/MPH or MD/JD. If an applicant is outside these requirements, then they must submit their reason for not staying within this rule (e.g. health reasons). It is better to submit an explanation in advance with proof so the application is not delayed.

Number of attempts

The number of attempts to pass various steps also affects applications. If an applicant failed more than two times in any exam, it signals authorities. An applicant must provide reasons, the most common reason being health or maternity.

Primary source verification

Primary source verification is one process that is time-consuming but important. All authorities will write to places applicants have graduated from and to residency program directors. Getting a response from medical schools for IMGs can be problematic. Submitting a certification of graduation is not enough. There are fake universities that will grant medical diplomas. To address that issue, U.S. authorities directly write the medical school and verify graduation, sometimes with scores in various subjects.

Many international medical schools may not respond to the inquiry promptly or may not answer at all. This delays the candidate’s license approval. When applying to multiple states or looking for reciprocity, remember that each state will do its own primary source verification. It is easy to bypass that requirement if a candidate has FCVS certification.

Completeness and accuracy

Incomplete or inaccurate information at any step of the process can create all kinds of headaches. Applications ask if there have been any disciplinary actions taken by any entity. If the answer is “no,” but the response from primary source verification describes an event the applicant did not describe in the application, the applicant could be labeled as dishonest and denied a medical license. This could include incidents so minor the applicant may have forgotten them.

This becomes even more important if an applicant was cited for driving under the influence (DUI) but failed to mention that in the application. These omissions can interfere with even license renewal. It is better to reveal everything rather than covering up or ignoring an issue or incident.

American medical graduates (AMGs) have their information automatically posted to their FCVS files by medical schools and residency or fellowship programs. This makes the process much easier and IMGs should utilize this avenue. FCVS is accepted by all medical boards as primary source verified information.

The initial application fee requires extra costs, but then the candidate can send that file for a nominal fee to other licensing authorities. This saves applicants time and effort.

MOLs and licensing compacts are complicated issues but apply to all equally (AMGs and IMGs).

Many hospitals, managed care organizations, licensing boards and other institutions may require that IMGs provide credentials verification directly from their medical school, even though most international medical graduates have their credentials evaluated by the Educational Commission for Foreign Medical Graduates.

All information should be verified with state licensing boards. Medical licenses are granted to those physicians meeting all state requirements and are at the discretion of the board.

Find more information on the AMA policies related to IMG state licensure with AMA's Policy Finder.

AMA obtains licensure information from the Federation of State Medical Boards. The licensure grid is updated every year. Direct questions to [email protected] to find current information on medical licensure requirements and statistics in the U.S., including state-by-state licensure information.

Learn more about the AMA member group International Medical Graduates Section and get involved in policy decision-making for issues affecting IMG physicians.