Medical Residency in the United States in 2026: Important Updates on the ECFMG Pathways

On July 30, 2025, the Educational Commission for Foreign Medical Graduates (ECFMG) published a notice about the opening of the application to the 2026 Pathways for certification and recertification. These processes are essential for medical students and graduates trained outside the United States who wish to enter residency programs or validate the medical certificates from their countries of origin. The announcement clarifies important changes compared to the Pathways of previous years and presents a preliminary calendar of actions for candidates planning to participate in the Match 2026. Below, we have gathered the main changes, compared them with the previous requirements, and offer practical guidance.

General context and future launches

The ECFMG uses the Pathways to assess the clinical and communication skills of physicians trained outside the USA, especially after the discontinuation of the USMLE Step 2 CS exam. For the year 2026, the application to the Pathways will be made available in August 2025, when the organization will launch MyIntealth™, a new online platform that will integrate different Intealth services. The organization plans to deactivate its current systems on August 14, 2025 for data migration; the launch of the new platform is expected to occur within 4–6 days, still in August. The exact opening date of the Pathways applications will be announced in the preceding week, but candidates should prepare to begin their applications as soon as the system is available.

Main changes in the 2026 Pathways compared to 2025

Aspect	2025	2026 (new)
English proficiency exam	Accepted OET Medicine taken after Jan 1, 2023.	All candidates must obtain a satisfactory score on the OET Medicine taken on or after Jan 1, 2024; this rule also applies to recertification requests.
Pathway 1 — Full medical license	License/registration valid at any time after Jan 1, 2020.	The license must be valid on or after Jan 1, 2021; the initial license date may be earlier, but it must have been renewed after Jan 1, 2021.
Pathway 2 — OSCE administered by an approved school	Required a graduation date on or after Jan 1, 2023.	Keeps the same graduation date; there was no change.
Pathways 3, 4, and 5 — Accredited schools	Required graduation on or after Jan 1, 2023 and an official attestation from the school.	The graduation requirements remain the same; there are no changes.
Pathway 6 —	Allowed encounters in a formal clinical setting, including offices, urgent care, emergency rooms, or hospitals.	Significant changes: the encounters must occur only in formal outpatient settings and the patients must be registered outpatients; encounters in the emergency room, units of urgent care, or inpatient admissions are not allowed. In addition, no patient may be a relative of the candidate (spouse, child, cousin, etc.) — this restriction already applied to the evaluators, but now also applies to the patients.
Pathway recertification	The final deadline to submit applications and documentation was May 31, 2025.	Complete details about recertification and deadlines for 2026 will be announced when MyIntealth is launched; however, candidates who need to recertify should pay attention to the new opening deadline in August 2025.

Description of the six 2026 Pathways

Pathway 1 – Full medical license in another country

This Pathway is intended for physicians who hold or recently held a full license to practice medicine without supervision in any country. For 2026, the ECFMG stipulates that the license must have been valid on or after Jan 1, 2021. Licenses obtained earlier are accepted only if they remained valid after that date. Candidates must demonstrate that their license has not been subject to disciplinary action and, if eligible, it is recommended to request certificates or letters of good standing from the regulatory authority as early as possible, since these documents must be sent to the ECFMG.

Pathway 2 – OSCE administered by a medical school

Indicated for students or recent graduates of medical schools that administer an Objective Structured Clinical Examination (OSCE) required for licensure in the country where the school is located (This is not the case in Brazil). The exam must meet the requirements established by the ECFMG. There was no change in the graduation date requirement: the candidate must have graduated on or after Jan 1, 2023. An authorized official of the school must attest to the candidate's clinical performance.

Pathways 3, 4, and 5 – Medical school accreditation

• Pathway 3 covers students or graduates of schools accredited by an agency recognized by the World Federation for Medical Education (WFME). In the case of Brazil, this agency is the Medical School Accreditation System (SAEME).
• Pathway 4 is aimed at schools whose accrediting body received a comparability determination from the National Committee on Foreign Medical Education and Accreditation (NCFMEA) → Does not work for the Brazilian candidate
• Pathway 5 serves programs in which the degree is issued jointly with a US medical school accredited by the Liaison Committee on Medical Education (LCME) → Does not work for the Brazilian candidate

 

For all of these Pathways, it is necessary to have completed medical school on or after Jan 1, 2023 and to obtain an attestation from the school that the candidate has adequate clinical skills.

Pathway 6 

Pathway 6 is intended for candidates who do not fit into the other Pathways or who need to recertify an expired Pathway. It requires the assessment of clinical skills through six in-person clinical encounters observed by licensed physicians. For 2026, the rules of this Pathway have been tightened:

1. Care settings – The encounters must occur exclusively in formal outpatient settings, with patients registered as outpatients. Encounters in emergency rooms, urgent care clinics, or with inpatients will not be accepted.
   
   
2. Relationship with the patient – The patient evaluated cannot be a relative of the candidate; the definition includes spouse, children, parents, grandparents, siblings, uncles/aunts, nieces/nephews, and cousins.
   
   
3. Evaluators – Each encounter must be observed by a physician with a full, unrestricted license for at least five years. Each physician may evaluate up to two encounters per candidate and cannot be a relative of or be paid by the candidate. These requirements already existed in 2025 and remain in effect.
   
   
4. Mini-CEX – The evaluator must complete an electronic form assessing the medical interview, physical examination, professionalism/communication, and clinical reasoning. Each item is scored from 1 to 9 and the final score is calculated as the average of the six encounters.
   
   

Interested candidates should begin identifying physician evaluators who meet the criteria, but it is important to remember that the assessments can only be carried out after the candidate submits their online application and the evaluator accepts the request in the system. Encounters carried out before that will not be considered.

Naturally, the most widely used Pathways for Brazilian physicians are Pathways 1 and 3, with the others being reserved for other types of candidates. 

What to do now – Early preparation

Although the complete application details will be released in August 2025, the ECFMG recommended a few immediate actions:

• Schedule the OET Medicine – All candidates for the 2026 Pathways (new or for recertification) need to have a satisfactory score on the OET Medicine obtained on or after Jan 1, 2024. The ECFMG recommends that those who intend to participate in the Match 2026 take the test before the last available date in December 2025.
  
  
• Documents for Pathway 1 – Candidates with a medical license should request certificates or letters of good standing from their registration/licensing authority in advance. If the authority can send the document directly to the ECFMG, the official email address provided by the organization should be used.
  
  
• Evaluators for Pathway 6 – Those who qualify only for Pathway 6 should review the criteria for evaluators and identify physicians willing to participate. The assessments must be submitted through the online platform after the application is submitted.
  
  
• Follow the transition to MyIntealth – The ECFMG confirmed that its systems will be deactivated on Aug 14, 2025 for migration and the new portal will be launched in 4–6 days. This transition includes changes to the fee structure and aims to improve the user experience. We comment more about this change in our post on our blog.
  
  
• Pathway recertification – If your Pathway-based ECFMG certificate has expired or is about to expire, you will need to validate it to participate in the Match 2026 and/or to take the USMLE Step 3. In the 2025 cycle, the final deadline for recertification was May 31, 2025; for 2026, wait for the opening of the new application period.
  
  

Approximate timeline for the IMG candidate (Match 2026)

Below we present a timeline with important events based on the information available as of July 31, 2025. Future dates may still be adjusted by the ECFMG or the NRMP.

Date / Period	Event / Recommended action	Source
Jan 1, 2024	Earliest date for OET Medicine results to be accepted for the 2026 Pathways	ECFMG
Jun 25, 2025	Availability of the ERAS 2026 Tokens. Candidates can use them to register on MyERAS and begin preparing their residency application	ECFMG
Jul 14, 2025 (approx.)	The ECFMG online systems will be intermittently down between Jul 18–20, 2025 for maintenance, preparing for the transition	ECFMG
Aug 14, 2025	Deactivation of the ECFMG systems for migration to MyIntealth; the new platform is expected to be launched in 4–6 days	ECFMG
August 2025	Opening of the application to the 2026 Pathways simultaneously with the launch of MyIntealth. The Information Booklet 2026 and the registration materials for USMLE Step 1/2 CK will also be released	ECFMG
Dec 2025	It is recommended to take the OET Medicine by the last available test date in December, ensuring that the results are available for the application	ECFMG
Early 2026	Probable deadline for submitting applications to the 2026 Pathways, based on the history of previous years (the 2025 deadline was Jan 31, 2025 for the 2025 Pathways). Await official confirmation.	ECFMG history
Mar 2026 (estimated)	Deadline for the ECFMG to inform the NRMP whether the candidate has met all the requirements (including Pathways and exams) before the Rank Order List Certification deadline.	NRMP
Jul 2026	Start of the residency programs for candidates approved in the Match 2026.	NRMP

Tips and best practices for candidates

1. Plan your study schedule – To complete a Pathway it is necessary to have already registered for at least one of the USMLE exams. Therefore, organize yourself to take Step 1 and Step 2 CK in advance, considering demand and the eligibility periods.
   
   
2. Keep your documentation up to date – Medical licenses, registration certificates, and school attestations can take weeks to be issued. Begin requesting these documents as early as possible.
   
   
3. Prepare for the OET Medicine – The English exam is mandatory for all the 2026 Pathways, regardless of native language or place of study. Review the OET score requirements and practice in advance.
   
   
4. Choose reliable evaluators (Pathway 6) – If you need Pathway 6, select physicians who meet the criteria, who can observe you in outpatient settings, and who are available to complete the Mini-CEX online within the deadlines.
   
   
5. Pay attention to the changes in the platform – The transition to MyIntealth may affect navigation and online services. Follow official communications and be prepared for possible instabilities in the first few days after the launch
   
   
6. Follow official channels – For updates, regularly consult the ecfmg.org website, the @intealthofficial profile on Instagram, and the email communications.
   
   

Essential information

For those who want a quick summary, the key points of the 2026 Pathways are:

• Opening of the application in August 2025 concurrently with the launch of MyIntealth™
  
  
• OET Medicine requirement – the result must be dated on or after Jan 1, 2024, for all Pathways (including recertification
  
  
• Pathway 1: the medical license must be valid on or after Jan 1, 2021
  
  
• Pathway 2 and Pathways 3–5: keep the graduation date of Jan 1, 2023
  
  
• Pathway 6: clinical encounters must be outpatient; patients cannot be relatives; settings such as the emergency room or inpatient admission are excluded
  
  
• It is recommended to schedule the OET as early as possible and prepare documentation/licenses or evaluators according to the chosen Pathway
  
  
• More details and deadlines will be released together with the Information Booklet 2026 and on the official ECFMG website