Med school and beyond: exams and licensing
Your board exams and licence,in the US and Canada.
Which exams you take, how you enter residency and who grants your licence all depend on where your degree comes from. Start with your background, then follow the route and the study plan.
Start with your degree
Choose the background that fits you to see the route on each side of the border.
Where is your medical degree from?
To train in the United States
USMLE Step 1, Step 2 CK and Step 3. Apply to residency through ERAS and the NRMP Match, then a state licence after the required training.
To train in Canada
You can apply to Canadian residency under CaRMS rules. US MD graduates from July 1, 2025 are classed as international medical graduates for the Canadian R-1 match.
The three USMLE Steps
Step 1 and Step 2 CK can be taken in either order. Step 3 comes after both, once you hold your degree. DO students take COMLEX-USA Levels 1, 2-CE and 3, and many add the USMLE.
Step 1Pass or fail
- What it tests
- The foundational sciences and how they explain health, disease and clinical reasoning.
- When
- Usually after the pre-clinical coursework, at the end of year 2 or after the first clinical year, depending on the school.
- Why it matters
- Required before Step 3, and part of ECFMG certification for international graduates.
Step 2 CKThree-digit score
- What it tests
- Clinical knowledge across the core disciplines: diagnosis, next steps and management.
- When
- During the clinical years, commonly before residency applications open.
- Why it matters
- The score carries real weight in residency applications; required for ECFMG certification.
Step 3Three-digit score
- What it tests
- Whether you can manage patients safely without supervision, including computer-based case simulations.
- When
- Usually during the first year of residency or later.
- Why it matters
- Completes the USMLE sequence, commonly needed for a full state licence. Taken only in the US and its territories.
The US route, step by step
- 01
Confirm eligibility and your registration route
Students and graduates of US MD and DO schools register with the NBME for all three Steps. International students and graduates file an ECFMG certification application first, then register with the FSMB.
- 02
Set up the right account
International graduates check that their school is listed in the World Directory of Medical Schools with an ECFMG sponsor note, then apply for ECFMG certification.
- 03
Pass Step 1 and Step 2 CK
Take them in either order, planned around your curriculum, rotations and the residency calendar.
- 04
International graduates: finish ECFMG certification
Alongside Step 1 and Step 2 CK, meet the clinical skills and communication requirement through one of ECFMG's 2027 pathways. Every pathway requires OET Medicine scores from a single sitting. Check the rules for your certification year.
- 05
Apply to residency
Most applicants use ERAS to apply and the NRMP Main Residency Match. You need transcripts, letters, a personal statement, the dean's letter (MSPE), exam results and interviews.
- 06
Train, then take Step 3
Step 3 usually comes during residency. Agree the timing with your program and the state board.
- 07
Apply for a state licence
Each state sets its own requirements: training completed, the USMLE sequence, credential checks and background checks. Board certification is a separate step.
A US planning timeline
A template, not a fixed schedule. Your curriculum and application year set the real dates.
| When | What to do | Ready when |
|---|---|---|
| Pre-clinical years | Learn the foundational sciences, use question banks alongside coursework, read the USMLE content outline and build a routine you can sustain. | Regular topic-based questions; weak subjects spotted early. |
| Step 1 dedicated studyoften 6–10 weeks | Consolidate organ systems, pathology, pharmacology, microbiology and physiology with practice questions and timed self-assessments. | Steady improvement on reputable self-assessments, and your school agrees you are ready. |
| Clinical clerkships | Prepare for Step 2 CK through patient care, shelf exams and mixed timed question blocks. | Broad coverage across disciplines; weak areas tracked. |
| Step 2 CK studyoften 6–12 weeks | Timed mixed blocks, case-based review, ethics, patient safety, biostatistics and self-assessments. | Stable practice scores and a realistic exam date. |
| Application year | Confirm the ERAS and NRMP calendar, gather letters, write your personal statement, apply and prepare for interviews. International graduates meet ECFMG deadlines. | Every document and certification ready before program and Match deadlines. |
| First year of residency | Settle into supervised practice, plan Step 3 and meet program milestones and state requirements. | Your program director agrees the Step 3 timing. |
The Canadian route
Canada does not use the USMLE. The Medical Council of Canada runs the exams, CaRMS runs the residency match, and each province or territory licenses its physicians.
- 01
physiciansapply.ca
Open an account and submit your medical credentials for source verification. Start early: verification depends on your school and can take time.
- 02
MCCQE
A one-day computer-based exam of medical knowledge and clinical decision-making at the level of a graduating Canadian medical student, called the MCCQE Part I until April 2026. Required for international graduates applying to residency. A pass plus a verified degree now earns the LMCC.
- 03
NAC exam
A half-day OSCE that checks readiness to enter Canadian residency, required for international graduates in the CaRMS R-1 match. Offered in spring and fall, with results about eight weeks later.
- 04
CaRMS R-1 match
Read the national and provincial eligibility rules, program descriptions, language requirements and citizenship or permanent-residence rules before you apply.
- 05
Provincial registration
After residency, apply to the medical regulatory authority in your province or territory. Registration, supervision and specialty certification rules vary.
Ways into Canadian practice
| Route | Who it may fit | Keep in mind |
|---|---|---|
| Canadian residency (CaRMS R-1) | Canadian graduates and eligible US or international graduates seeking Canadian training. | International graduates generally need the MCCQE and NAC, Canadian citizenship or permanent residence, and the province's criteria. |
| Practice-ready assessment (PRA) | Experienced internationally trained physicians with postgraduate training and independent practice. | Nine provinces run one, usually a 12-week clinical assessment in the workplace, often for family medicine and often with a return-of-service commitment. Prince Edward Island and the territories have none. |
| Specialist certification | Experienced specialists trained outside Canada. | Royal College routes include approved-jurisdiction, ACGME-trained and Practice Eligibility routes. Eligibility depends on specialty and training; certification is not automatic. |
| Provisional or other provincial registration | Physicians who meet a province's alternative registration category. | Only the provincial or territorial regulator can confirm eligibility, scope, supervision and conditions. |
A Canadian planning timeline
12–18+ months ahead
Choose your province and route, check citizenship or permanent residence and international-graduate eligibility, open physiciansapply.ca and start source verification.
One province's international-graduate rules do not apply nationally.
6–12 months before applying
Prepare for the MCCQE, check exam sessions, practise NAC cases and communication, and gather translations and references.
The MCCQE and NAC have separate applications and booking windows.
Before CaRMS deadlines
Pass the required exams, confirm provincial eligibility, and prepare your CV, personal statement, references and program documents.
CaRMS dates change each year; follow the current match calendar.
Applications and interviews
Apply to programs you are eligible for, prepare for interviews and structured scenarios, and rank carefully.
The match is competitive.
After the match
Complete accredited residency, the remaining exams and provincial registration, then specialty certification.
Training length depends on the specialty.
Experienced international physicians
If residency is not the best fit, ask the target province and college about practice-ready or specialist routes.
These routes carry their own experience, assessment and practice requirements.
The US and Canada side by side
| United States | Canada | |
|---|---|---|
| Exams | USMLE Steps 1, 2 CK and 3; DO graduates may use COMLEX-USA. | The MCCQE, plus the NAC for international graduates entering residency. |
| Residency entry | ERAS application and the NRMP Match. | The CaRMS R-1 Match. |
| International graduates | ECFMG certification before accredited residency. | No single national certificate; MCC credential and exam steps plus provincial eligibility. |
| Who licenses | State medical boards. | Provincial and territorial medical regulatory authorities. |
| After the exams | Residency and state board requirements still apply. | Residency or an eligible alternative route, plus provincial registration. |
How to prepare for each exam
USMLE Step 1
- Plan the week by organ system: physiology, pathology, pharmacology, microbiology, immunology, genetics and behavioural science.
- Do question blocks consistently, review every answer including lucky guesses, and keep an error log.
- Use spaced repetition for mechanisms, drug effects, organisms and high-yield associations.
- Take timed blocks and full-length self-assessments, and adjust the plan from the trend rather than one score.
- Read the official content outline and sample questions to learn the scope and format.
USMLE Step 2 CK
- Study by discipline: medicine, surgery, pediatrics, obstetrics and gynecology, psychiatry and preventive care.
- Prioritise diagnosis, the next best step, management, complications, screening, ethics and patient safety.
- Work mixed, timed clinical vignettes and learn why each distractor is wrong.
- Practise biostatistics, epidemiology, quality improvement, communication and professionalism questions.
- Take several self-assessments and book the exam once your scores and clinical readiness hold steady.
USMLE Step 3
- Review outpatient, inpatient, emergency, preventive and long-term patient management.
- Practise the computer-based case simulations with legitimate preparation resources.
- Review drug dosing, adverse effects, diagnostic testing, prognosis and management over time.
- Agree the timing with your residency program.
MCCQE and NAC
- For the MCCQE, practise broad clinical reasoning, diagnosis and management, prevention, population health and ethics against the MCC objectives.
- For the NAC, practise timed OSCE stations: focused history, exam, counselling and explaining a diagnosis or plan with empathy.
- Use a steady station structure: introduce yourself, confirm identity and consent, gather information, summarise, explain, agree a plan and safety-net.
- Practise with peers or trained standardized patients and ask for feedback on clarity, empathy, organisation and timing.
- Review the Canadian context: preventive screening, public health, ethics and patient-centred care.
A sample study week
| Day | Core study | Practice and review |
|---|---|---|
| Monday to Thursday | Focused review by system or discipline. | 40–80 timed questions a day, with detailed review and the error log. |
| Friday | Weak topics and high-yield notes. | A mixed timed block, plus biostatistics, ethics or communication practice. |
| Saturday | A longer integrated session. | A self-assessment or an OSCE circuit, then review. |
| Sunday | Light review and recovery. | Spaced repetition, plan the next week, and rest. |
What changed recently
- From July 1, 2025 Canadian medical schools are accredited by CACMS alone, no longer jointly by the LCME. Canadian graduates from that date apply to US residency as international medical graduates and need ECFMG certification.
- CaRMS made the matching change for the Canadian R-1 match: US MD graduates from July 1, 2025 are classed as international medical graduates, with an exception for some combined-degree students who began the MD by the end of 2020.
- USMLE registration moved in January 2026: international students and graduates now register for every Step through the FSMB instead of ECFMG, and US students and graduates register for Step 3 through the NBME instead of the FSMB.
- The Medical Council of Canada renamed the MCCQE Part I to the MCCQE in April 2026, and since January 2026 the LMCC no longer requires a year of postgraduate training.
- ECFMG pathways, OET requirements, fees, eligibility windows, CaRMS provincial criteria and exam dates change every year, so this page avoids treating any of them as permanent.
Verify with the official source
- USMLE service transition Who registers you for each Step since January 2026.
- USMLE eligibility Who can take each Step, and in what order.
- USMLE path to licensure How the Steps fit into a US medical licence.
- FSMB: getting started with USMLE USMLE registration for international students and graduates.
- ECFMG certification Requirements and current pathways for international medical graduates.
- World Directory of Medical Schools Check a school's listing and ECFMG sponsor note.
- MCCQE Medical Council of Canada exam eligibility and application.
- NAC exam The OSCE for international graduates entering Canadian residency.
- MCC pathways for international graduates Every Canadian route for physicians trained abroad.
- CaRMS R-1 eligibility National and provincial criteria for the residency match.
- CaRMS R-1 timeline This cycle's application and match dates.
- Royal College exam eligibility Specialist certification routes for physicians trained outside Canada.
MedStride is not affiliated with these organizations. The official page wins over anything written here.
Keep going
Inside medical school
The four years, the doctoring course, standardized patients and how rotations run.
Residency and match
Which tracks require it, how each match runs, and the months that matter.
Letters
The three-plus rule, who signs for each track, and how letters reach the portal.
Interviews and travel
Four phases from the first offer to the rank list, with the setup and travel that make it work.
Match Day videos
Real ceremonies from medical schools: see the day students learn where they will train.
Fellowships
Optional subspecialty years after residency, by track.