Licensure guide · Updated September 29, 2026

From Step 1 to a full license: the U.S. medical licensure guide

Q: How many years of residency do you need to get a medical license?

It depends on the state. Most states license graduates of U.S. and Canadian medical schools after 1 year of accredited residency (PGY-1), some require 2, and a few, including California, Kansas and Maine, require 3. International medical graduates usually need 2 to 3 years.

Q: Can you get a medical license without finishing residency?

In many states, yes. A full, unrestricted license often requires only 1 or 2 years of postgraduate training, not a completed residency. Board certification and most attending jobs still require a completed residency.

Q: Can foreign doctors practice in the U.S. without residency?

In a growing number of states, yes. Since 2023 more than 20 states have passed laws creating provisional licenses for experienced internationally trained physicians with an in-state job offer. After a supervised period they can become eligible for a full license in that state.

Q: When should I take USMLE Step 3?

You need an MD or DO degree (or ECFMG certification as an IMG) and passing results on Step 1 and Step 2 CK. Most residents take Step 3 during PGY-1 or early PGY-2. Many boards limit attempts and require all Steps to be passed within a set number of years, often seven.

Q: How much can medical students borrow in federal loans?

For new borrowers from July 1, 2026, Grad PLUS loans are no longer available, and professional students can borrow up to $50,000 per year and $200,000 in total in Direct Unsubsidized loans. Students who already had loans for their program before that date may keep the old limits for a limited time.

Q: Should residents refinance medical school loans?

Refinancing federal loans into a private loan can lower the interest rate, but it permanently ends eligibility for Public Service Loan Forgiveness and federal income-driven repayment. Residents at nonprofit hospitals who plan to pursue PSLF usually keep their loans federal.

Every exam, certificate and training year between medical school and a full, unrestricted U.S. medical license, for U.S. MD and DO students and international medical graduates. Plus how to pay for it.

How many years of residency do you need for a medical license?

Every state medical board sets its own minimum amount of accredited postgraduate training (GME), counted in PGY years. For graduates of U.S. and Canadian medical schools, most states grant a full license after one year (PGY-1, the intern year). A smaller group requires two years, and a few, including California, Kansas and Maine, require three.

International medical graduates usually face a longer minimum, typically two or three years, though a few states such as Colorado, Michigan, Minnesota and Oklahoma apply the same one-year rule to everyone. Some states credit training completed abroad or waive part of the requirement for board-certified physicians. Compare every state on the map or open any state page.

A license is not the same as finishing residency. You can often hold a full state license after PGY-1 or PGY-2, but specialty board certification, hospital privileges and most attending jobs still require a completed residency.

Board certification: ABMS and ABPS

A state license lets you practice; specialty board certification shows you completed training in a specialty and passed its exams. The major certifying bodies, the member boards of the American Board of Medical Specialties (ABMS) and the American Board of Physician Specialties (ABPS), generally require completion of a U.S. or Canadian ACGME-accredited residency. Most hospitals and insurers expect certification for attending positions, so physicians licensed through an alternative IMG pathway should check how their state and employer treat certification.

The licensing exams: USMLE and COMLEX

Every state requires a passing score on a national licensing exam sequence. MD students and IMGs take the United States Medical Licensing Examination (USMLE). DO students take COMLEX-USA from the NBOME, and many also take the USMLE to widen their residency options.

Exam	Usually taken	Scoring	What it covers
USMLE Step 1	End of year 2	Pass/fail since 2022	Basic sciences applied to medicine
USMLE Step 2 CK	Year 3 or 4	3-digit score	Clinical knowledge and patient care
USMLE Step 3	PGY-1 or PGY-2	3-digit score	Unsupervised practice, two days
COMLEX Level 1	End of year 2	Pass/fail since 2022	Osteopathic basic sciences
COMLEX Level 2-CE	Year 3 or 4	3-digit score	Osteopathic clinical knowledge
COMLEX Level 3	During residency	3-digit score	Generalist practice

With Step 1 now pass/fail, Step 2 CK carries most of the weight in residency applications. Students usually build a dedicated study period of four to eight weeks around a question bank, practice tests (NBME self-assessments for the USMLE, COMSAE for COMLEX) and a review resource. See board exam prep for more.

USMLE Step 3 and attempt limits

To sit for Step 3 you need an MD or DO degree (or ECFMG certification as an IMG) and passing results on Step 1 and Step 2 CK. Most residents take it during intern year, because H-1B visas and several state training licenses require it and the material is fresh. Many boards cap the number of attempts on each Step and require all three to be passed within a set window, often seven years. Focus prep on the Computer-based Case Simulations (CCS), the least familiar part of the exam.

Residency: the Match and PGY years

Graduates enter residency through the NRMP Main Residency Match. Applications open through ERAS in early fall, interviews run through winter, and results are released on Match Day in March. Training starts around July 1. Each year of residency is a postgraduate year: PGY-1 (intern year), PGY-2 and so on, and state boards measure their training requirement in these years or in months.

ECFMG certification for international medical graduates

Graduates of medical schools outside the U.S. and Canada must be certified by the Educational Commission for Foreign Medical Graduates (ECFMG) before entering an accredited residency. Certification requires passing USMLE Step 1 and Step 2 CK, meeting ECFMG's clinical and communication skills requirement (including English proficiency), and verification of your medical diploma and final transcript. Your school must be listed in the World Directory of Medical Schools with an ECFMG note.

Alternative licensure pathways for international physicians

Since 2023, more than 20 states have passed laws that let experienced physicians trained and licensed abroad practice without repeating a U.S. residency. The details vary, but most share the same pieces:

An unrestricted license in good standing from another country and several years of recent practice
ECFMG certification or passing USMLE Step 1 and Step 2 CK
A job offer from an in-state hospital or health system, often in a rural or underserved area
A provisional or limited license with supervision for two to six years, then eligibility for a full license in that state only

The IMG pathways section lists every state with an operative pathway, and each state page says whether its pathway exists. Georgia and Vermont have enacted pathways that aren't taking applicants yet. Many boards are still writing rules, so ask whether the pathway is open for applications. The Federation of State Medical Boards tracks these laws in its key issues by state.

Visas for international medical graduates

Most IMG residents train on a J-1 visa sponsored by ECFMG, which carries a two-year home-country residence requirement afterward. The Conrad 30 program lets each state recommend up to 30 waivers a year for physicians who commit to three years of work in an underserved area. Some programs sponsor the H-1B instead, which usually requires passing Step 3 first.

Physician shortage and demand by state

Supply varies widely by state. Using active physicians per 100,000 residents, states such as Idaho, Mississippi, Oklahoma, Wyoming, Arkansas and Nevada have the thinnest coverage, while Massachusetts, Maryland and New York have the most. Lower supply generally means more job openings, stronger recruiting incentives and more loan repayment programs. See the physician demand map and the jobs and salary map.

Applying for your state medical license

Confirm the state's training minimum and exam rules on its state page, then on the board's own site.
Build a credentials file with the FSMB Federation Credentials Verification Service (FCVS); many boards require or accept it, and it saves time for later states.
Submit the application with transcripts, exam scores, training verification from your program director and fingerprints for a background check.
If you plan to practice in several states, check whether they belong to the Interstate Medical Licensure Compact (IMLC), which speeds up additional licenses for board-certified physicians.
Register for a DEA number and any state controlled-substance registration once licensed.

Paying for it: medical school loans

Federal loans after July 1, 2026

Federal borrowing for medical school changed on July 1, 2026. Grad PLUS loans are closed to new borrowers, and professional students can now borrow up to $50,000 a year and $200,000 in total in Direct Unsubsidized loans. Students who already had Direct Loans for their program before that date can keep borrowing under the old rules for a limited transition period. For many students the new caps leave a gap that must be covered by school aid, scholarships, service programs or private loans.

Private medical school loans

Private lenders offer medical school loans with in-school deferment that often extends through residency. Compare fixed versus variable rates, whether a cosigner is required, and how long payments stay deferred during training. Private loans do not qualify for federal forgiveness.

Scholarships and service programs

The National Health Service Corps, the military Health Professions Scholarship Program (HPSP) and many state loan-repayment programs pay tuition or repay loans in return for years of service, often in the same shortage areas shown on our demand map.

Student loans during residency

A resident's salary is modest compared with typical medical school debt, so most residents choose an income-driven payment rather than the standard 10-year plan. Loans made on or after July 1, 2026 use the new income-based Repayment Assistance Plan (RAP) or a standard plan.

Public Service Loan Forgiveness (PSLF) forgives the remaining federal Direct Loan balance after 120 qualifying monthly payments made while working full time for a qualifying employer. Most residency programs are at nonprofit or public hospitals, so residency years can count.

Refinancing into a private loan can cut the interest rate, and some lenders offer low fixed payments during residency. The trade-off is permanent: refinanced loans lose PSLF eligibility, federal income-driven plans and federal deferment. Decide on PSLF first.

Loan terms change; confirm current limits at StudentAid.gov and with your school's financial aid office.

Glossary of medical licensure terms

ABMS: American Board of Medical Specialties, the umbrella for 24 specialty certifying boards.
ABPS: American Board of Physician Specialties, an alternative certifying body for several specialties.
ACGME: Accreditation Council for Graduate Medical Education, which accredits U.S. residency and fellowship programs.
COMLEX-USA: The osteopathic licensing exam series (Levels 1, 2-CE and 3).
ECFMG: Educational Commission for Foreign Medical Graduates, which certifies IMGs for U.S. residency.
ERAS: Electronic Residency Application Service, used to apply to residency programs.
FCVS: FSMB's Federation Credentials Verification Service, which stores verified credentials for license applications.
FSMB: Federation of State Medical Boards, which represents state boards and co-sponsors the USMLE.
GME: Graduate medical education: residency and fellowship training after medical school.
HPSA: Health Professional Shortage Area, a federal designation for places with too few clinicians.
IMG: International medical graduate: a physician who graduated from a medical school outside the U.S. and Canada.
IMLC: Interstate Medical Licensure Compact, an expedited multi-state licensing process.
NRMP / The Match: National Resident Matching Program, which pairs applicants with residency positions each March.
PGY-1, PGY-2…: Postgraduate year of training. PGY-1 is the intern year.
PSLF: Public Service Loan Forgiveness, which forgives federal loans after 120 qualifying payments.
RAP: Repayment Assistance Plan, the income-based federal repayment plan for loans made from July 1, 2026.
SPEX: Special Purpose Examination, a knowledge exam some boards use for licensure by endorsement or reinstatement.
USMLE: United States Medical Licensing Examination: Step 1, Step 2 CK and Step 3.

Frequently asked questions

How many years of residency do you need to get a medical license?

It depends on the state. Most license U.S. and Canadian graduates after 1 year, some require 2, and California, Kansas and Maine require 3. IMGs usually need 2 to 3 years.

Can you get a medical license without finishing residency?

In many states, yes. A full license often requires only 1 or 2 years of training. Board certification and most attending jobs still require a completed residency.

Can foreign doctors practice in the U.S. without residency?

In a growing number of states, experienced internationally trained physicians with an in-state job offer can get a provisional license and, after a supervised period, a full license in that state.

When should I take USMLE Step 3?

After earning your MD or DO (or ECFMG certification) and passing Step 1 and Step 2 CK. Most residents take it during PGY-1 or early PGY-2.

How much can medical students borrow in federal loans?

For new borrowers from July 1, 2026, Grad PLUS is gone and professional students can borrow up to $50,000 a year and $200,000 in total in Direct Unsubsidized loans.

Should residents refinance medical school loans?

Refinancing can lower the rate but permanently ends PSLF and federal income-driven repayment. Residents planning on PSLF usually keep their loans federal.

This guide is general information, not legal or financial advice. Licensing rules change often. Confirm every requirement with the state medical board, and talk to a qualified financial professional before refinancing loans.