The Pathway to Medical Licensure

The pathway to medical licensure is a complex process that differs between U.S medical graduates and international medical graduates (IMGs). The Federation of State Medical Boards (FSMB) provides a visual aid of the designated steps and definitions. To view the graphic with definitions, click here

How Doctors Become Licensed in the U.S.

In the U.S., the practice of medicine is licensed and regulated by the individual states. There are 70 total state medical boards, including 14 osteopathic boards and medical boards for the following territories: Guam, Puerto Rico, the U.S. Virgin Islands and the Commonwealth of the Northern Mariana Islands. While the specific requirements for obtaining a medical license vary somewhat between states, all state medical boards review the professional background information of applicants and look closely at a number of factors, including: 

  • Medical education
  • Medical training (i.e., residency training)
  • Performance on a national licensing examination 

Medical Education

All states require that candidates for medical licensure have earned an MD or DO degree from an accredited medical school. For most medical schools in the U.S., the MD or DO degree involves a post-baccalaureate four-year program (residency). Graduates of international medical schools (IMGs) may present the equivalent of the MD degree.

There are 151 allopathic and 34 osteopathic medical schools in the U.S. All of these medical school programs are accredited by either the Liaison Committee on Medical Education (LCME) or the American Osteopathic Association Commission on Osteopathic College Accreditation (AOA COCA). 

It should be noted that acquisition of an MD or DO degree does not automatically confer a license to practice medicine in the U.S. The Medical Practice Act in most states restricts individuals holding a medical license from publicly representing themselves as doctors unless they hold a medical license in that state. 

Medical Training

All state medical boards require candidates seeking a medical license to complete at least one year of postgraduate training, commonly known as a residency, in order to be eligible for a full and unrestricted medical license. In some states, the requirement is higher — the doctor must complete two or three years of residency training to obtain a license. In more than a dozen states, progress through postgraduate training requires a doctor to successfully complete the licensing examination sequence and obtain a full, unrestricted license prior to reaching a designated point in their postgraduate training. 

The postgraduate training period often marks the first formal interaction of prospective doctors with a state medical board, as most boards issue a resident or training permit for doctors to practice within the limited, supervised context of their residency program. 

Additionally, state medical boards require that the training be completed in a residency program accredited by either the Accreditation Council for Graduate Medical Education (ACGME) or the American Osteopathic Association (AOA). These programs are approximately three to seven years in duration, depending upon the specialty.

Licensing Examination

All state medical boards require completion of either the United States Medical Licensing Examination (USMLE®) or the Comprehensive Osteopathic Medical Licensing Examination (COMLEX-USA). These are national multi-part examinations taken at various points in a prospective doctor’s career and designed to assess the doctor’s knowledge, clinical and communication skills. Students in U.S. medical schools routinely take the first two steps of the licensing examination prior to graduation from medical school. The final step of the examination is usually taken during residency training. 

Many state medical boards limit the number of attempts a doctor can make to pass the USMLE or COMLEX-USA. Additional attempts are often allowed, but only after doctors have been redirected for additional training prior to taking the exam again. Most state medical boards also place restrictions on the time period for completing the examination sequence. These time- and attempt-limits are designed to ensure the currency and adequacy of knowledge of newly licensed doctors. More detailed information on “State-Specific Requirements for Initial Medical Licensure” is available from the FSMB here.