About Physician Licensure

How Physicians Gain Licenses to Practice Medicine

In the United States, medicine is a licensed profession regulated by the individual states. One of the most important functions of the nation’s state medical boards is issuing licenses to physicians. Through licensing, state medical boards ensure that all practicing physicians have appropriate education and training, and that they abide by recognized standards of professional conduct while serving their patients.

Obtaining a license to practice medicine in the U.S. is a rigorous process. Those entering the profession must meet predetermined qualifications that include medical school graduation, postgraduate training, and passage of a comprehensive national medical licensing examination that tests their knowledge of health and disease management and effective patient care. Applicants must submit proof of their education and training and provide details about their work history. They also must reveal information that may affect their ability to practice, such as health status, malpractice judgments/settlements and criminal convictions. Only those who meet a state’s qualifications are granted permission to practice medicine in that state.

After physicians are licensed, they must renew their license periodically, usually every one or two years, to continue their active status. During this license renewal process, physicians must demonstrate that they have maintained acceptable standards of ethics and medical practice and have not engaged in improper conduct. In nearly all states, physicians must also show that they have participated in a program of continuing medical education.

While the specific requirements for obtaining a medical license vary somewhat between jurisdictions, state medical boards review the credentials 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
Mental, moral, and physical fitness to safely practice medicine

Medical Education: All jurisdictions require that candidates for physician licensure have obtained an MD or DO degree. For most medical education programs in the United States, the MD or DO degree involves a post-baccalaureate four-year program of education. Graduates of international medical schools (IMGs) may present the equivalent of the MD degree (e.g., MBBS).

There are 155 allopathic and 37 osteopathic medical schools in the United States. 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 United States. The medical practice act in most jurisdictions restricts individuals holding a physician credential from publicly representing themselves as physicians unless they hold a medical license in that jurisdiction.

Medical Training: After graduation from medical school, physicians routinely enter into postgraduate training – usually a residency training program. At one time it was common for physicians to spend their first year of postgraduate training (PGY-1) in an internship exposing them to a broad array of clinical scenarios. After this intern year, the physician then moved into the more specialized training of their chosen residency training program. Most physicians today do not experience a true rotating internship during PGY-1 but instead move directly into the specialized training of their residency program.

All state medical boards require licensure candidates to complete at least one year of postgraduate training in order to be eligible for a full and unrestricted medical license. In some jurisdictions, the requirement is higher — the physician must complete two or three years of residency training to obtain a license. In more than a dozen jurisdictions, progress through postgraduate training requires a physician to successfully complete the licensing examination sequence and obtain a full, unrestricted license prior to reaching a designated point in their postgraduate training. For example, some jurisdictions require physicians in training to complete the licensing examination sequence prior to entering PGY-2 or PGY-3.

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

For many years, state medical boards required 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). In 2014, the AOA, ACGME, and the American Association of Colleges of Osteopathic Medicine (AACOM) agreed to a single accreditation system for graduate medical education programs in the United States, which was implemented in 2020 and now unifies the various programs.

These programs are approximately three to seven years in duration, depending upon the specialty.

Some state medical boards recognize training in the accredited programs conducted in other countries – for example, residency programs accredited by the Royal College of Physicians and Surgeons of Canada.

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). The USMLE is open to physicians holding an MD or DO degree. Physicians with a DO degree usually complete the COMLEX-USA sequence.

These are national multi-part examinations taken at various points in a prospective physician’s career and designed to assess the physician’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 sequence is usually taken during residency training.

Many boards limit the number of attempts a physician can make to pass the USMLE or COMLEX-USA. Additional attempts are often allowed, but only after physicians have been redirected for additional training prior to taking the exam again. Most 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 physicians.

More detailed information on State-Specific Requirements for Initial Medical Licensure is available at the FSMB website.

Fitness to practice: All state medical boards are concerned with the physical, mental, and moral fitness of prospective licensure candidates. A number of boards explicitly define the practice of medicine in their licensure applications to ensure that physicians clearly understand the expectations for minimally acceptable performance. The licensure application in each state commonly asks questions about the personal history and background of the applicant, including work history, physical and/or mental conditions that might impact their ability to safely practice medicine. Criminal background checks at the time of license application are also conducted by many boards.

Compared with U.S. medical graduates, IMGs follow a slightly different pathway after completing their medical education at a school outside the United States. Before entering into a residency training program in the United States, they must be certified by the Educational Commission for Foreign Medical Graduates (ECFMG). This certification is required in order for IMGs to enter into an ACGME-accredited residency training program in the United States. ECFMG certification requires verification of the physician’s medical degree and successful completion of USMLE Step 1 and 2. The timing with which IMGs complete the USMLE differs somewhat from that of U.S. medical students and graduates. While some IMGs begin the USMLE sequence during their medical school years, many more do not begin the sequence until after their graduation from medical school. Ultimately, IMGs take the same licensing examinations as U.S. MD graduates and obtain residency training in the same accredited programs.

When a physician applies for a medical license, staff at the state medical board receiving the application will verify the physician’s credentials (e.g., medical degree, postgraduate training), confirm that the physician has successfully passed the USMLE or COMLEXUSA, query the FSMB’s disciplinary data bank and closely review the physician’s responses to questions on the licensure application for missing or inconsistent information. In some instances, the board may request that the physician appear for a formal interview before either the full board or a subcommittee of the board.

The license that the physician eventually receives from a state medical board is for the general, undifferentiated practice of medicine. Physicians in the United States are not licensed based upon their specialty or practice focus. Certification in a medical specialty, such as by a member board of the American Board of Medical Specialties (ABMS) or the AOA’s Bureau of Osteopathic Specialists (AOA BOS), is not required to obtain a medical license. However, other practical considerations — such as obtaining hospital privileges — lead most physicians to obtain specialty certification. The majority of physicians in the United States hold specialty certification through the ABMS or AOA BOS.

The Interstate Medical Licensure Compact

In 2015, a group of U.S. state medical boards joined together to launch the Interstate Medical Licensure Compact, which offers a new, expedited pathway to licensure for qualified physicians who wish to practice in multiple states.

A compact is a legal agreement, authorized by the Compact Clause of the U.S. Constitution, that allows states to collectively work together to address shared needs or issues. There are more than 200 interstate compacts in effect today.

Among the issues driving the need for the Interstate Medical Licensure Compact are physician shortages, the recent influx of millions of new patients into the health care system, and the growing need to increase access to health care for individuals in underserved or rural communities through the use of telemedicine. Proponents of telemedicine have often cited the state-by-state licensure process required for multiple-license holders as a barrier to telemedicine’s growth, and the Compact is intended to help overcome this hurdle.

In addition to significantly streamlining the process of gaining medical licenses in multiple states for physicians, the Interstate Medical Licensure Compact is designed to increase access to health care for patients in underserved or rural areas, and to allow them to more easily connect with medical experts through the use of telemedicine technologies. Any state or territory may join the Compact, but in order for a state or territory to join the Interstate Medical Licensure Compact, its legislature must enact the Compact into law.

As of 2020, 29 states, Guam, and the District of Columbia are participating members of the Compact, with several other states actively considering legislation to join.

States participating in the Compact formally agree to adopt common rules and procedures that streamline medical licensure, thus substantially reducing the time it takes for physicians to obtain multiple state licenses. The Interstate Medical Licensure Compact Commission provides oversight and the administration of the Compact, creating and enforcing rules governing its processes, but each participating state maintains its individual authority and control over the practice of medicine within its borders. Participating states retain the authority to issue licenses, investigate complaints, and discipline physicians practicing in their state.

To be eligible for licensure by utilizing the Compact process, physicians must possess a full and unrestricted license in a Compact member state, be certified (or “grandfathered”) in a medical specialty, have no history of being disciplined, penalized or punished by a court, a medical licensing agency or the Drug Enforcement Administration, and meet several other robust requirements.

To participate, an eligible physician designates a member state as the State of Principal Licensure and selects the other member states in which a medical license is desired. Upon receipt of this verification in the additional Compact states, the physician is granted a separate, full and unrestricted license to practice in each of those states.

To date, more than 10,000 medical licenses have been issued using the Compact process.

The Compact is voluntary for both states and physicians. Physicians who cannot or do not want to participate in the Compact’s expedited licensure process are still able to seek additional licenses in those states where they desire to practice by applying through that state’s traditional and existing licensure processes.

To learn more, please visit www.imlcc.org.

Pathway to Physician Licensure in the United States

The FSMB has created a visual illustration of the pathway physicians must take in order to become licensed in the United States.

The definitions below explain terminology used in the Pathway to Medical Licensure illustration:

Open All / Close All

The American Association of Colleges of Osteopathic Medicine Application Service is a centralized application service for colleges of osteopathic medicine in the United States through the American Association of Colleges of Osteopathic Medicine®.

The American Medical College Application Service®, a program of the Association of American Medical Colleges, is a centralized application processing service that is only available to applicants to first-year entering classes at participating allopathic (MD) U.S. medical schools.

The Comprehensive Osteopathic Medical Licensing Examination (COMLEX-USA) is a multi-part assessment given by the National Board of Osteopathic Medical Examiners (NBOME) to students and graduates of osteopathic medical education programs accredited by the American Osteopathic Association’s Commission on Osteopathic College Accreditation. The NBOME eligibility criterion requires COMLEX Level 1 to be taken after successful completion of the first academic year of an osteopathic medical school program. Level 2 Cognitive and Performance Evaluations (CE and PE) cannot be taken until after successful completion of the second academic year and passing Level 1. The COMLEX-USA Level 3 is usually taken during residency training and after successful completion of Levels 1-2, though in certain circumstances Level 3 may be taken by osteopathic medical school graduates prior to beginning residency training.

The Educational Commission for Foreign Medical Graduates (ECFMG) provides a certification program for international medical graduates (IMGs) to assess their readiness prior to entering into ACGME-accredited residency or fellowship training programs in the United States.

The Electronic Residency Application Service (ERAS®) was developed by the Association of American Medical Colleges (AAMC) to allow medical school students and graduates to apply electronically for residency positions in accredited U.S. programs of graduate medical education.

The Federation Credentials Verification Service, a service of the Federation of State Medical Boards, establishes a permanent, lifetime repository of primary-source verified core credentials (medical education, postgraduate training, examination history, board action history, board certification and identity) for physicians and physician assistants/associates. This repository can be forwarded, at the applicant’s request, to nearly any state medical board, hospital, health care facility or other entity.

The Interstate Medical Licensure Compact offers a new, voluntary, expedited pathway to licensure for qualified physicians who wish to practice in multiple states. While making it easier for physicians to obtain licenses to practice in multiple states, the Compact strengthens public protection by enhancing the ability of states to share investigative and disciplinary information. The Compact is being implemented in a growing number of states, with others expected to adopt it soon (www.imlcc.org).

The Medical College Admission Test® is a standardized, multiple-choice examination designed to assess the examinee’s problem solving, critical thinking, knowledge of science concepts and principles prerequisite to the study of medicine.

The American Board of Medical Specialties (ABMS) assists 24 approved medical specialty boards in the development and use of standards in the ongoing evaluation and certification of physicians. In 2000, the 24 Member Boards of ABMS agreed to evolve their recertification programs to one of continuous professional development — ABMS Maintenance of Certification® (ABMS MOC®). In 2006, all Member Specialty Boards received approval of their ABMS MOC programs, which have 8-10 year renewal cycles.

The National Resident Matching Program provides a uniform date of appointment to positions in graduate medical education (GME). It provides an impartial venue for matching applicants’ and programs’ preferences for each other consistently.

The American Osteopathic Association (AOA) Bureau of Osteopathic Specialists consists of 18 specialty certifying boards. Effective in 2013, each AOA specialty-certifying board requires an Osteopathic Continuous Certification (OCC) process for all doctors of osteopathic medicine (DOs) with time-limited certifications. OCC runs on a 6-10 year cycle depending upon the specific specialty board.

The Uniform Application, a service of the Federation of State Medical Boards, is a Web-based application that standardizes, simplifies, and streamlines the licensure application process for MDs, DOs and Residents. Applicants fill out the online UA once and then use it whenever they apply for a license in another participating state for the rest of their careers. The UA is a standard licensure application form that serves as the core of a state’s license application without replacing unique state-level requirements, which are collected and submitted via a state-specific addendum.

The United States Medical Licensing Examination® (USMLE®) is a jointly sponsored program of the Federation of State Medical Boards and the National Board of Medical Examiners®. The USMLE is open to students/graduates of accredited medical school programs issuing the MD or DO degree and to students/graduates of international medical schools eligible for certification by the ECFMG. In general, Step 1 is usually taken at the end of the second academic year of medical school; Step 2 Clinical Knowledge (CK) and Step 2 Clinical Skills (CS) are generally taken before the end of the third academic year. Most examinees take Step 3 within the first 18 months of residency training, though under certain circumstances some IMGs and U.S. medical school graduates may take Step 3 prior to beginning residency training.

About Physician Licensure

The definitions below explain terminology used in the Pathway to Medical Licensure illustration:

AACOMAS

AMCAS®

COMLEX-USA

ECFMG®

ERAS®

FCVS

IMLC

MCAT®

MOC®

NRMP®

OCC

UA

USMLE®