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US residency path for IMGs, step by step from medical school to the Match

Omar Saad, MBBCh· 11 min read

If you're an international medical graduate (IMG), the US residency path can look like one giant wall of acronyms: ECFMG, USMLE, OET, ERAS, NRMP, SOAP. Most guides explain all of it at once, which is why most readers finish them still unsure what to do on Monday.

This guide works the other way round. Start by finding where you are now, jump to that section, and do the next three things. Every requirement and date below comes from the official source, and each one is named so you can check it yourself.

I'm an IMG myself (MBBCh), and I cold-emailed US physicians before building IMG Outreach. This is the map I wish I'd had.

Where are you now?

Find the row that sounds like you. It tells you which section to read and the three things to do next.

  • Still in medical school (Still in medical school): 1. Check your school has an ECFMG Sponsor Note. 2. Plan for Step 1. 3. Line up a US elective or research early.
  • Graduated, studying for Step 1 (or Step 2 CK) (Graduated and studying): 1. Open your MyIntealth account. 2. Pass Step 1, then Step 2 CK. 3. Start research outreach while you study.
  • Passed Step 1 and Step 2 CK (Passed both Steps): 1. Complete an ECFMG Pathway (OET Medicine). 2. Get your diploma verified. 3. Start emailing for US clinical experience.
  • ECFMG certified, no US experience (Certified, no US experience): 1. Get an observership or research spot. 2. Earn US letters of recommendation. 3. Get your documents ready for ERAS.
  • Applying this cycle (Applying this cycle): 1. Register for the NRMP Match by January 29, 2027. 2. Meet and report exam requirements by March 3, 2027. 3. Certify your rank order list by March 3, 2027.

The whole path in one view

Before the details, here is the full route as a checklist. Each line is a stage this guide covers.

  • Your medical school is listed in the World Directory of Medical Schools with an ECFMG Sponsor Note
  • MyIntealth Applicant Portal account opened
  • USMLE Step 1 passed
  • USMLE Step 2 CK passed
  • ECFMG Pathway completed, including OET Medicine
  • Final medical diploma received and verified by ECFMG
  • US clinical experience and research (where US letters come from)
  • Letters of recommendation from US physicians
  • ERAS application submitted, with documents sent through ECFMG
  • NRMP Match registration and rank order list certified
  • Match Day, or SOAP if you don't match
  • Step 3, later, once you're in residency

If you're still in medical school

You have the most time of anyone reading this. Use it.

Check your school first

According to ECFMG, your medical school must be listed in the World Directory of Medical Schools with an ECFMG Sponsor Note. Without that note, students and graduates of the school are not eligible for ECFMG Certification. Check this before you spend a single dollar on exam prep.

ECFMG also requires at least 4 credit years at a listed school. If you're thinking of transferring or doing a shortened program, check how it counts.

Plan for Step 1

The USMLE says Step 1 is pass/fail for exams taken on or after January 26, 2022. A pass is still required, and you'll need Step 2 CK as well before you can be certified.

Get a US elective or research early

If your school can arrange a US elective, take it seriously. It gives you US clinical experience and the chance to work with a physician who can later write you a letter.

If you've graduated and are studying for the USMLE

Open your MyIntealth account

ECFMG says IMGs apply for ECFMG Certification through the MyIntealth Applicant Portal, and you need an account to do it. Opening it early means you're not learning a new system under deadline pressure.

Pass Step 1, then Step 2 CK

ECFMG Certification requires passing both USMLE Step 1 and Step 2 CK. These are the exam half of certification. The other half is clinical and communication skills, which is the Pathway (next section).

Don't let study time be empty time

Study months don't have to be empty months. Remote or part-time research alongside your studying gives you something to talk about, and a US physician who knows your work. A short, specific email to a researcher whose papers you've actually read is how most of these start. Our guide to cold emailing a doctor for research has a template.

If you've passed Step 1 and Step 2 CK

You've cleared the exams. Two certification pieces are left, and you should start building US experience at the same time.

Complete an ECFMG Pathway (and OET Medicine)

This is the part most guides skip. ECFMG says clinical and communication skills are met through an ECFMG Pathway, which includes a satisfactory score on the Occupational English Test (OET) Medicine. A valid pass on the former Step 2 CS also counts.

Why it matters so much: according to ECFMG, an accepted, unexpired Pathway is required to become ECFMG Certified, and it is also required to participate in the NRMP Match. The different Pathways are listed on ECFMG's Pathways page. Read it carefully and pick the one that fits your situation.

Get your diploma verified

ECFMG requires documented receipt of your final medical diploma, and it verifies every diploma with the school that issued it. Verification depends on your school responding, so start this as soon as you have the diploma in hand.

Start emailing for US clinical experience

Don't wait for your certificate to start this. Observerships and research can take a while to arrange. See how to email a US doctor for an observership.

If you're ECFMG certified but have no US experience

Certification is a big milestone. ECFMG notes that the ACGME requires IMGs entering ACGME-accredited residency or fellowship programs to be ECFMG certified. But certification alone doesn't give programs a picture of how you work in a US hospital. That's what US experience and US letters do.

Get an observership or research position

This is the stage where outreach matters most. A physician who hosts you can introduce you to colleagues, include you in projects and, later, write about you. Start with how to email a doctor for an observership and how to cold email a doctor for research.

Earn US letters of recommendation

Letters of recommendation are one of the documents ECFMG handles for IMGs in ERAS. A letter from a US physician who has seen you work is worth far more than one from someone who barely knows your name. Read why US letters of recommendation decide so much and how to ask for one.

Get your ERAS documents ready

ECFMG handles these ERAS documents for IMGs:

  • MSPE (the Medical Student Performance Evaluation, which replaced the old "Dean's letter")
  • Medical school transcript
  • Letters of recommendation
  • Photograph
  • USMLE transcript

Request your MSPE and transcript from your school well before you apply. For the 2027 season, ECFMG recommended sending them by September 11.

Step 3 can wait

The USMLE says Step 3 requires passing Step 1 and Step 2 CK plus a valid ECFMG Certificate. It also recommends having completed, or nearly completed, at least one postgraduate year of accredited US graduate medical education first.

If you're applying this cycle

How ERAS and ECFMG fit together

The AAMC describes ERAS as the centralized online application service that delivers your application and supporting documents to residency programs. Since ERAS began in 1996, ECFMG has served as the designated Dean's office for students and graduates of international medical schools. In practice, that means your school documents go through ECFMG, not straight to programs.

The 2027 cycle in dates

Here are the official dates for the current cycle (the 2027 Match), from the AAMC's ERAS timeline for IMGs and the NRMP's 2027 Main Residency Match calendar.

  • June 4, 2026: ERAS season opened (AAMC)
  • June 24, 2026: ECFMG issued ERAS tokens (AAMC)
  • September 2, 2026: Applicants could submit to programs (AAMC)
  • September 11, 2026: ECFMG's recommended date to send MSPE and transcript (ECFMG)
  • September 15, 2026: NRMP Match registration opened (NRMP)
  • September 23, 2026: Programs could begin reviewing applications (AAMC)
  • January 29, 2027: Standard NRMP registration deadline (late fee after) (NRMP)
  • February 1, 2027: Rank order list opens (NRMP)
  • March 3, 2027: Rank order list certification deadline (also late-registration deadline) (NRMP)
  • March 15, 2027: Match Week starts, match status released (NRMP)
  • March 18, 2027: SOAP offer rounds; SOAP ends (NRMP)
  • March 19, 2027: Match Day (noon ET) (NRMP)
  • May 31, 2027: ERAS season ends (AAMC)

If you're reading this for a later cycle, check the AAMC and NRMP sites for that year's dates. They haven't been published yet, and they're not guaranteed to follow this pattern.

You don't need your certificate to enter the Match

This surprises a lot of IMGs. ECFMG states you do not need to be ECFMG certified to participate in the Match (ECFMG). But the exam requirements must be met and reported by the NRMP rank order list deadline, which for the 2027 Match is March 3, 2027. NRMP says the same. And remember from the Pathway section: an accepted, unexpired Pathway is required to participate in the Match.

If you don't match: SOAP

The NRMP's Supplemental Offer and Acceptance Program (SOAP) is for applicants who did not match or only partially matched. It happens during Match Week, so know how it works before March, not after.

Visas

ECFMG is designated by the US Department of State as the J-1 sponsor for exchange visitor physicians in accredited graduate medical education. Details are on ECFMG's Exchange Visitor Sponsorship page.

What the 2026 Match numbers mean for you

The NRMP's March 2026 press release gives a clear picture of the competition:

  • Over 53,000 applicants registered, and more than 44,000 residency positions were offered.
  • The PGY-1 match rate for non-US-citizen IMGs declined to 56.4 percent, the lowest in five years.
  • The rate for US-citizen IMGs rose to 70 percent, the highest on record.

You can't change your citizenship. You can change what's in your application. The parts IMGs control most directly are the ones in the middle of this guide: US clinical experience, research and letters from US physicians.

Why many personalized emails matter

Every one of those parts usually starts the same way: an email to a physician who doesn't know you. Observerships, research positions and the letters that come out of them rarely appear on a job board.

Two things are true at once:

  • You need volume. Busy physicians don't all reply, and many can't host anyone.
  • Each email has to be personal. A copied email sent to a list gets ignored. One that mentions the physician's own work gets read.

Doing both by hand means researching and writing for dozens or hundreds of physicians. That's the problem IMG Outreach solves: it researches each physician and writes an email about their own work. You review every draft and send it from your own Gmail. You can start with 25 free drafts.

Frequently asked questions

Do I need ECFMG Certification before I apply to residency?

Not to enter the Match. ECFMG says certification isn't required to participate, but your exam requirements must be met and reported by the NRMP rank order list deadline, and you need an accepted, unexpired Pathway.

What is the OET, and why does it matter?

The Occupational English Test (OET) Medicine is part of an ECFMG Pathway, which is how ECFMG checks clinical and communication skills. An accepted Pathway is required both for ECFMG Certification and to participate in the NRMP Match.

Is Step 1 still scored?

No. The USMLE says Step 1 is pass/fail for exams taken on or after January 26, 2022. You still need to pass it.

When should I take Step 3?

Step 3 requires a valid ECFMG Certificate, and the USMLE recommends completing, or nearly completing, at least one year of US residency first. For most IMGs it comes after the Match.

What happens if I don't match?

If you don't match or only partially match, you can take part in the NRMP's SOAP during Match Week. For the 2027 Match, SOAP ends on March 18, 2027.

How do I get US clinical experience as an IMG?

Usually by emailing physicians directly for an observership, elective or research spot. Our guide to emailing a doctor for an observership walks through it with a template.