Getting licensed to practice in the United States

Medical and health education in the United States

US medical education is a graduate programme. Applicants first complete a bachelor’s degree with pre-medical coursework, then four years of medical school leading to an MD or a DO. Programmes are accredited by the Liaison Committee on Medical Education (LCME) for MD degrees and by the Commission on Osteopathic College Accreditation (COCA) for DO degrees. There are well over 150 MD-granting and a growing number of DO-granting schools. Teaching is in English.

Graduation is only the first step. Doctors pass USMLE (or COMLEX-USA for DO students) and then enter residency, which lasts three to seven years depending on specialty; the first year is called the internship. Each state medical board issues the licence, and most states require at least one to three years of accredited postgraduate training before a full licence. International graduates are certified through ECFMG before they can enter residency.

Nursing can be entered through a two-year associate degree or a four-year bachelor’s degree, with the NCLEX-RN for licensure. Pharmacy is the PharmD, usually four professional years after pre-pharmacy study. Dentistry is a four-year DDS or DMD after a bachelor’s degree.

What makes the US different

Most countries have one regulator per profession that sets the exam and issues the license. The US splits those jobs. National organizations write and score the exams, and 50-plus state and territory boards decide who is licensed to practice within their borders. A passing score on a national exam is necessary almost everywhere, but it is never the whole story: each state adds its own requirements for fees, background checks, jurisprudence and supervised hours.

The second difference is volume and money. The NCLEX-RN alone had 245,743 first-time candidates in 2025, of whom 192,916 were educated in the US and 52,827 were educated internationally. That makes it the largest single licensing exam in the region by headcount.

Who needs a licensing exam in the US

Everyone does. Unlike several countries on this site, there is no recognition-only route for the major professions. What changes for an internationally trained applicant is the set of steps that come before the exam.

Physicians: USMLE and COMLEX-USA

The United States Medical Licensing Examination is sponsored by the Federation of State Medical Boards (FSMB) and the National Board of Medical Examiners (NBME). It has three steps.

• Step 1 tests basic science principles. It is pass/fail. The exam has been run as up to 280 questions in seven 60-minute blocks over eight hours; the USMLE announced a restructure from 14 May 2026 into 14 blocks of 30 minutes with up to 20 items each. Check usmle.org for the format that applies to your test date.
• Step 2 CK tests clinical knowledge over one day. It is scored, and since Step 1 went pass/fail it has become the main number residency programs use to compare applicants through the NRMP Match.
• Step 3 is taken by residents and combines multiple-choice questions with computer-based case simulations over two days. It is the last exam required for full licensure.

Osteopathic students follow COMLEX-USA from the National Board of Osteopathic Medical Examiners (NBOME). Levels 1 and 2-CE are needed to graduate from accredited schools, and Level 3 is taken from the first year of residency.

International medical graduates (IMGs) enter through the Educational Commission for Foreign Medical Graduates (ECFMG), which verifies credentials and requires Step 1 and Step 2 CK before an applicant can enter the Match. Both exams are taken at Prometric centers worldwide, so you can sit them from your home country.

Step 2 CK has a second use. Together with Step 1, a pass is accepted as one of the written prerequisites for the New Zealand NZREX Clinical examination, within five years.

1. Confirm your medical school and graduation year are eligible under ECFMG rules, then open your ECFMG account.
2. Pass Step 1, then Step 2 CK, ideally within a short window so the scores read as one block.
3. Obtain ECFMG certification and apply for residency through the Match.
4. Pass Step 3 during residency and apply to a state medical board.

Nurses: NCLEX-RN

The National Council of State Boards of Nursing (NCSBN) writes the NCLEX-RN, the Next Generation NCLEX. It is a computer-adaptive test: the software selects each question from your previous answers, so the length varies, and the exam runs for up to five hours. The Next Generation format adds case-study items to the standard multiple-choice questions.

The same exam is used well beyond the US. Canadian provincial regulators outside Quebec use it, and the Nursing and Midwifery Board of Australia uses it as the first stage of its outcome-based assessment for some overseas nurses. A single preparation effort therefore covers three countries.

The order matters. You apply to a state board first, the board declares you eligible, and only then do you register with the test provider. Internationally educated nurses can sit at Pearson VUE centers in countries including India and the Philippines. Many states also require a credentials review by an approved evaluation service and proof of English proficiency, and the timeline for those documents is usually longer than the exam preparation itself.

Pharmacists: NAPLEX, MPJE and the FPGEE

The National Association of Boards of Pharmacy (NABP) runs the pharmacy exams. US PharmD graduates sit the NAPLEX, a computer-based multiple-choice exam, and most states also require the Multistate Pharmacy Jurisprudence Examination (MPJE) on state law.

Foreign-educated pharmacists go through the Foreign Pharmacy Graduate Equivalency Committee (FPGEC) first. The Foreign Pharmacy Graduate Equivalency Examination (FPGEE) is 200 multiple-choice items in a fixed form, 4.5 hours of testing in a 5.5-hour seat. It is offered once a year and only at Pearson sites in the continental US, which means international candidates must travel. After the FPGEE come the TOEFL iBT, supervised intern hours, the NAPLEX and the MPJE.

Dentists: INBDE

The Integrated National Board Dental Examination (INBDE) replaced the older NBDE Parts I and II. It is a case-based multiple-choice exam over two days at Prometric: day one is 8 hours 15 minutes and day two is 4 hours 15 minutes. It is run by the Joint Commission on National Dental Examinations.

The INBDE is not the whole of dental licensure. States also require a clinical licensure exam such as those run by ADEX or CDCA. Foreign dentists generally cannot license directly: they usually complete the INBDE and then enter a two-year advanced-standing DDS or DMD program, which is the route to a US degree and clinical eligibility.

Physical therapists and midwives

The Federation of State Boards of Physical Therapy (FSBPT) runs the NPTE-PT, a computer-based exam in five sections. Foreign-educated therapists have their credentials evaluated first, for example by FCCPT, and some jurisdictions add a jurisprudence exam. The separate NPTE-PTA is for assistants.

The American Midwifery Certification Board (AMCB) certifies Certified Nurse-Midwives and Certified Midwives through a computer-based exam. Eligibility rests on a graduate-level program accredited by ACME, so there is no shortcut for internationally trained midwives.

Exams compared

Language and recognition

Every US licensing exam is in English. Applicants who were not educated in English must usually show a language score as well: the TOEFL iBT appears in the FPGEC pharmacy pathway, and ECFMG and state boards set their own language requirements. There is no mutual recognition between the US and other countries comparable to the EU directive. Instead, foreign credentials are evaluated one applicant at a time.

That has a practical consequence. The US is a high-barrier system, but the barriers are sequential and documented. Candidates who plan the order of steps early, in particular state selection, credential evaluation and exam booking, avoid most of the delays.

TriagePass is independent of the NBME, NCSBN, NABP and every other organization named on this page. Our practice questions are original and written to the published content outlines.

Last reviewed October 2026