FSMB and US State Medical Boards: How US Licensing Works

There is no single national medical licence in the United States. The right to practise medicine is granted state by state, by medical licensing authorities that each set their own rules. The Federation of State Medical Boards (FSMB) is the national organisation that brings these boards together, and it co-owns the United States Medical Licensing Examination (USMLE) with the National Board of Medical Examiners (NBME).

For international medical graduates (IMGs), both matter. The FSMB is the organisation you register with for USMLE Step 1 and Step 2 CK. The state board is the one that eventually grants your licence. This page explains who does what and how the pieces fit together.

Key facts

What the FSMB does

The FSMB was founded in 1912 as a forum where state boards exchange best practices. Today it acts as a national voice for its member boards. Its services include:

• USMLE. The FSMB co-owns the exam program with the NBME.
• Credentials verification. The FSMB runs a credentials verification service that physicians can use in state licensing.
• Physician data. It maintains a physician data center used by boards.
• Policy work. Member boards shape policy through the FSMB House of Delegates.

The FSMB itself does not license or discipline anyone. That authority stays with each board.

What state medical boards do

Each state's medical licensing authority:

• grants the licence to practise medicine;
• sets its own rules and regulations;
• requires an exam that shows you are qualified for licensure;
• receives USMLE results to support initial licensure;
• investigates patient complaints and disciplines physicians who violate the law.

Some states have separate boards for MD and DO (osteopathic) physicians. Requirements such as the number of years of US postgraduate training, attempt limits on the USMLE, or time limits for completing all Steps differ between boards.

USMLE and the licence

The USMLE has three Steps. US boards use it as the exam pathway to licensure for MD graduates and for IMGs. In practice:

Students and graduates of medical schools outside the US apply for Step 1 and Step 2 CK through the FSMB, while students and graduates of LCME- or COCA-accredited US programs apply through the NBME. See our USMLE Step 1 guide and USMLE Step 2 CK guide for format, fees and pass rates.

Path for international medical graduates

A typical sequence for an IMG who wants to practise in the US:

1. Check your school. Your medical school must meet ECFMG requirements; eligibility is checked in the World Directory of Medical Schools.
2. Register for USMLE Step 1 and Step 2 CK. IMGs apply through the FSMB.
3. Get ECFMG Certification. Besides the two exams, you meet clinical and communication skills requirements, currently through Pathways and the OET Medicine. Read our ECFMG/Intealth guide.
4. Enter residency. Most IMGs enter US graduate medical education through the Match.
5. Take Step 3. Usually during residency.
6. Apply to a state board. Each board has its own training, exam and documentation requirements. Start reading your target state's rules early, because they can affect which residency you choose.

Step 1 is the first real gate. If you want to start practising questions now, MediFlow's USMLE Step 1 course offers free test questions.

Typical mistakes

• Thinking the FSMB grants licences. It doesn't; only state boards do.
• Assuming one national rule. Attempt limits, postgraduate training years and Step time limits are set board by board.
• Ignoring licensing when choosing residency. Some states have specific rules for IMGs. Check before you rank programs.
• Registering with the wrong organisation. IMGs register for Step 1 and Step 2 CK through the FSMB, not the NBME.
• Forgetting ECFMG. USMLE passes alone do not make you eligible for residency as an IMG; ECFMG Certification is also needed.

Fees

For USMLE fees, see our Step guides. State licence fees vary widely by board.

Contact and official links

• FSMB: fsmb.org
• USMLE: usmle.org
• USMLE eligibility: usmle.org/bulletin-information/eligibility
• ECFMG Certification: ecfmg.org/certification

For your target state, go to that state's official medical board website. Our next read: Working as a Doctor in the USA.