100+ Free ECFMG Certification Practice Questions

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Step 1 IMG ~73-82%, Step 2 CK IMG ~83-91%, OET Medicine ~70-80% first-attempt Pass Rate

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Question 1

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A 24-year-old man presents with right lower quadrant pain, nausea, and fever. McBurney's point tenderness with rebound. WBC 16,000. What is the most likely diagnosis?

Diverticulitis

Renal colic

Cholecystitis

Acute appendicitis

to track

2026 Statistics

Key Facts: ECFMG Certification Exam

$925

2026 Pathways App Fee

ECFMG 2026 Pathways

350/300

OET Medicine Min Scores

L/R/S 350; Writing 300; one sitting

214

Step 2 CK Passing Score

USMLE effective July 2024

Jan 31

2026 Pathways Deadline

ECFMG for 2026 Match

ECFMG Pathways

Apply in order; CS failures go direct to 6

Permanent

Certification Validity

Once issued, does not expire

ECFMG Certification is the gateway credential for IMGs entering US residency, requiring USMLE Step 1 (pass/fail), USMLE Step 2 CK (passing score 214), one of six Pathways (1 license; 2 OSCE/exam; 3-5 medical school attestation with Mini-CEX; 6 ECFMG Mini-CEX), and OET Medicine (350 Listening/Reading/Speaking; 300 Writing). The 2026 Pathways application fee is $925 with a January 31, 2026 deadline for 2026 Match eligibility. IMG first-attempt pass rates are ~73-82% on Step 1 and ~83-91% on Step 2 CK. Certification is permanent and is required for ERAS application, NRMP Match participation, and J-1 visa sponsorship.

Sample ECFMG Certification Practice Questions

Try these sample questions to test your ECFMG Certification exam readiness. Each question includes a detailed explanation. Start the interactive quiz above for the full 100+ question experience with AI tutoring.

1A 55-year-old man presents with crushing substernal chest pain radiating to his left arm for 30 minutes. ECG shows ST elevation in leads II, III, and aVF. What is the most likely diagnosis?

A.Anterior STEMI

B.Inferior STEMI

C.Lateral STEMI

D.Pericarditis

Explanation: ST elevation in leads II, III, and aVF indicates an inferior wall STEMI, typically due to occlusion of the right coronary artery (RCA). Management includes urgent reperfusion (PCI within 90 minutes or fibrinolysis if PCI unavailable), aspirin, P2Y12 inhibitor, anticoagulation, and beta-blockers.

2As of January 2026, ECFMG uses Pathways to verify English proficiency for IMGs. Which pathway requires passing the OET Medicine?

A.Pathway 1

B.Pathway 6

C.All pathways equally

D.Only US-trained IMGs

Explanation: Pathway 6 (English Language Proficiency) requires passing the OET Medicine with minimum scores of 350 in each subtest. Other Pathways (1-5) primarily verify clinical skills competency through approved licensing exam pathways, medical school clinical assessments, or direct ECFMG clinical skills evaluation.

3A 60-year-old woman with type 2 diabetes presents with proteinuria 2 g/day, normal serum creatinine. Which medication is most appropriate to slow nephropathy progression?

A.Lisinopril (ACE inhibitor)

B.Amlodipine

C.Hydrochlorothiazide

D.Metoprolol

Explanation: ACE inhibitors (or ARBs) are first-line for diabetic nephropathy with proteinuria, reducing intraglomerular pressure and proteinuria. They slow progression to ESRD even in normotensive patients. SGLT2 inhibitors are now also recommended for renal protection in T2DM (DAPA-CKD, EMPA-KIDNEY trials).

4A 28-year-old G1P0 at 24 weeks presents with elevated blood pressure 150/100 and proteinuria. She has no prior history of HTN. Diagnosis?

A.Chronic hypertension

B.Gestational hypertension

C.Preeclampsia

D.HELLP syndrome

Explanation: Preeclampsia: new-onset HTN (SBP >=140 or DBP >=90) after 20 weeks with proteinuria (>=300 mg/24h, P/C ratio >=0.3, or dipstick >=2+) OR severe features (thrombocytopenia, LFTs, renal insufficiency, pulmonary edema, neurologic symptoms). Management: aspirin prevention, magnesium for severe, delivery at term.

5A 70-year-old man presents with progressive memory loss, gait disturbance, and urinary incontinence. Brain MRI shows enlarged ventricles. What is the most likely diagnosis?

A.Alzheimer disease

B.Normal pressure hydrocephalus

C.Parkinson disease

D.Vascular dementia

Explanation: NPH classic triad: 'wet, wacky, and wobbly' (urinary incontinence, dementia, gait apraxia). MRI shows enlarged ventricles disproportionate to brain atrophy. Treatment: ventriculoperitoneal shunting can dramatically improve symptoms, especially gait. Large-volume LP (Miller-Fisher test) helps predict shunt response.

6ECFMG certification has what time limit (the '7-year rule')?

A.All USMLE Steps must be completed within 7 years of passing the first Step

B.Application must be submitted within 7 years

C.License must be obtained within 7 years

D.ECFMG certificate expires after 7 years

Explanation: The 7-year rule: all USMLE Steps (Step 1, Step 2 CK, Step 3) must be completed within 7 years of passing the first Step. Exceptions may apply for those who fail and need extra time. After 7 years, previously passed Steps must be retaken. This applies to all USMLE candidates including US IMGs and IMGs.

7A 24-year-old man presents with right lower quadrant pain, nausea, and fever. McBurney's point tenderness with rebound. WBC 16,000. What is the most likely diagnosis?

A.Acute appendicitis

B.Diverticulitis

C.Cholecystitis

D.Renal colic

Explanation: Acute appendicitis: periumbilical pain migrating to RLQ, anorexia, nausea/vomiting, fever, leukocytosis. Classic signs: McBurney's point tenderness, Rovsing's sign, psoas sign, obturator sign. Diagnosis: clinical + imaging (CT in adults, ultrasound in children/pregnant women). Treatment: appendectomy.

8A 50-year-old smoker presents with weight loss, hemoptysis, and a 4 cm lung mass on CXR. Biopsy shows non-small cell lung cancer. What is the next step in staging?

A.PET-CT scan

B.Bone scan only

C.MRI brain only

D.Repeat CXR in 3 months

Explanation: NSCLC staging: PET-CT scan to evaluate mediastinal lymph nodes and distant metastases. MRI brain for staging (especially T1c, T2-T4 disease). EBUS or mediastinoscopy for tissue confirmation of N2 disease. Staging guides treatment: surgery for I/II, chemoradiation for III, systemic therapy for IV.

9A 32-year-old woman G2P1 at 38 weeks presents in labor. Cervix is 6 cm dilated, 100% effaced, +1 station. Fetal heart rate is 140 with reassuring pattern. What is the most appropriate management?

A.Immediate cesarean section

B.Allow normal labor progression with monitoring

C.Administer magnesium sulfate

D.Forceps delivery now

Explanation: Active phase of labor (6+ cm) is progressing normally with reassuring fetal status. Continue monitoring (intermittent or continuous FHM), encourage mobility, hydration, support. Vaginal delivery is the goal. Cesarean is for non-reassuring fetal status, arrest of labor, or maternal indications.

10A 4-year-old presents with high fever, sore throat, drooling, and tripod position. He looks toxic. What is the appropriate initial management?

A.Examine throat with tongue depressor first

B.Avoid throat examination, urgent OR transfer for controlled intubation with ENT and anesthesia

C.IM ceftriaxone and discharge

D.Lateral neck X-ray in radiology

Explanation: Suspected epiglottitis: AVOID throat examination (can precipitate complete airway obstruction). Keep child calm and upright. Transfer to OR/ICU for controlled airway management with ENT and anesthesia. Empiric ceftriaxone after airway secured. Hib vaccine has dramatically reduced epiglottitis incidence.

About the ECFMG Certification Exam

ECFMG Certification is the credential required for international medical graduates (IMGs) to enter US graduate medical education (residency and fellowship). It is administered by the Educational Commission for Foreign Medical Graduates, a division of Intealth, and requires passing USMLE Step 1 and Step 2 Clinical Knowledge (CK), completing one of six Pathways for the clinical skills requirement, and achieving minimum scores on the Occupational English Test (OET) Medicine for the communication skills requirement. Once issued, ECFMG Certification is permanent and is a prerequisite for the NRMP Main Residency Match and for J-1 visa sponsorship by ECFMG.

Questions

100 scored questions

Time Limit

Multi-component: USMLE Step 1 (~8 hr), Step 2 CK (~9 hr), OET Medicine (~3 hr per sitting), Pathway evaluation (varies)

Passing Score

Step 1: pass/fail. Step 2 CK: 214. OET Medicine: 350/350/350/300 (L/R/S/W).

Exam Fee

$925 Pathways app + ~$1,065 Step 1 + ~$1,065 Step 2 CK + ~$587 OET Medicine + ECFMG application fee (Educational Commission for Foreign Medical Graduates (ECFMG), a division of Intealth, in partnership with FSMB, NBME, and OET)

ECFMG Certification Exam Content Outline

~20%

USMLE Step 2 CK — Internal Medicine

Cardiology — ACS (STEMI D2B <=90 min, DAPT), HFrEF four-pillar GDMT, AF CHA2DS2-VASc + DOAC, HTN ACC/AHA stage 1 >=130/80. Pulmonology — COPD GOLD (LABA+LAMA, ICS for exacerbator), asthma GINA (ICS-formoterol Track 1), CAP CURB-65, PE Wells/PERC/age-adjusted D-dimer. GI — variceal bleed (octreotide, ceftriaxone, EGD <=12 h), IBD, hepatitis A/B/C, cirrhosis complications. Renal — AKI prerenal/intrinsic/postrenal, CKD staging, hyperkalemia. Endo — diabetes ADA 2026, thyroid, adrenal insufficiency, pheochromocytoma.

~15%

USMLE Step 2 CK — Obstetrics, Gynecology & Pediatrics

OB — prenatal screening, preeclampsia (>=140/90 + proteinuria or end-organ; Mg sulfate seizure prophylaxis, target 4-7 mg/dL, monitor reflexes), gestational diabetes (1-hr GCT >=140 then 3-hr GTT), postpartum hemorrhage (atony — oxytocin/methylergonovine/carboprost/misoprostol/TXA), ectopic (beta-hCG, transvaginal US). Peds — well-child ACIP schedule, milestones (rolls 4 mo, sits 6 mo, walks 12 mo), febrile infant <60 days full sepsis workup, bronchiolitis supportive only, croup (dexamethasone, racemic epi if stridor at rest), Kawasaki (IVIG + ASA).

~13%

USMLE Step 2 CK — Psychiatry, Neurology & Behavioral

Psych — DSM-5-TR depression PHQ-9 SSRI first-line, bipolar I lithium 0.6-1.2 (TSH, Cr monitor), schizophrenia atypical AP with metabolic monitoring, suicide risk (C-SSRS), alcohol withdrawal CIWA-Ar (thiamine BEFORE glucose), MOUD (buprenorphine/methadone/naltrexone). Neuro — stroke (NIHSS, tPA <=4.5 h, thrombectomy <=24 h LVO), seizure first-line levetiracetam/lamotrigine, migraine (triptan ER, NSAID, antiemetic), Alzheimer (cholinesterase inhibitors, memantine), Lewy body (REM behavior + visual hallucinations, AVOID typical APs), MS (steroids acute), GBS (IVIG/PLEX), myasthenia (pyridostigmine).

~12%

USMLE Step 2 CK — Surgery & Emergency Medicine

Acute abdomen — appendicitis (McBurney, Rovsing, psoas), cholecystitis (Murphy, HIDA), SBO (air-fluid levels, NG decompression), perforation (free air on CXR/CT), mesenteric ischemia (pain out of proportion). Trauma — ATLS ABCDE primary survey, FAST exam, massive transfusion 1:1:1. AAA screening (men 65-75 ever-smoker) and dissection (Stanford A — surgery; B — medical). Sepsis 1-hour bundle (cultures BEFORE antibiotics, lactate, broad-spectrum, 30 mL/kg crystalloid). DKA (fluids first, insulin drip, K when <5.2). Hyperkalemia (calcium gluconate, insulin+D50, kayexalate/patiromer).

~20%

USMLE Step 1 — Foundational Sciences

Biochem — glycolysis/TCA/electron transport, urea cycle, fatty acid synthesis vs beta-oxidation, vitamin deficiencies (B1 Wernicke, B6 sideroblastic, B9/B12 macrocytic, C scurvy, D rickets/osteomalacia, K coagulopathy). Microbio — gram-positive cocci (staph, strep, enterococcus), gram-negatives (enterics, Pseudomonas), atypicals (Mycoplasma, Chlamydia, Legionella), TB, HIV opportunistic. Pharm — first-pass metabolism, P450 inducers/inhibitors, NSAIDs/acetaminophen, antibiotics. Pathology — neoplasia, granulomas, amyloid. Genetics — autosomal dominant/recessive, X-linked, mitochondrial. Embryology, behavioral sciences, biostatistics (sensitivity/specificity, RR/OR, NNT).

~10%

OET Medicine & Communication

OET Medicine has four sub-tests scored A-E: Listening (~45 min, healthcare workplace audio across 3 parts), Reading (~60 min, 3 parts including matching, gap-fill, MCQs based on healthcare texts), Writing (~45 min, one letter — referral/discharge/transfer of care), Speaking (~20 min, 2 role-plays as a health professional with an interlocutor playing patient). ECFMG requires minimum 350 (B grade) on Listening, Reading, and Speaking AND minimum 300 on Writing in ONE test administration. Patient-centered communication, plain language, teach-back, empathic acknowledgment, SOAP/SBAR documentation.

~5%

ECFMG Application & Pathways 1-6

Application via myIntealth (online portal). Medical school must appear in the World Directory of Medical Schools (WDOMS) with an active Sponsor Note. Six Pathways — Pathway 1: applicants currently or recently licensed to practice medicine. Pathway 2: applicants whose school confirms a structured/objective clinical-skills exam (OSCE Attestation if no diploma yet). Pathways 3-5: medical-school clinical-skills attestations via Mini-CEX, reviewed by dean. Pathway 6: ECFMG-administered Mini-CEX evaluated by licensed physicians across six clinical encounters covering Interviewing, Physical Exam, Professionalism/Communication, and Clinical Reasoning. Apply in order (1->2->3->4->5->6); applicants who failed Step 2 CS may apply directly to Pathway 6.

~5%

US Healthcare System, Match & Residency

NRMP Main Residency Match — register September of MS-IV/post-graduate year, ERAS opens for applicants, programs review applications October-December, interviews October-January, rank order list due late February, Match Day mid-March, SOAP (Supplemental Offer and Acceptance Program) for unmatched candidates the same week. ERAS via AAMC MyERAS. J-1 visa sponsored by ECFMG (no obligation to return home unless 2-year home rule, waivable). H-1B visa requires program sponsorship and USMLE Step 3. ABMS specialty certification post-residency. ACGME accreditation. Sub-specialty fellowship matches via NRMP Specialty Matches or AAMC SF Match.

How to Pass the ECFMG Certification Exam

What You Need to Know

Passing score: Step 1: pass/fail. Step 2 CK: 214. OET Medicine: 350/350/350/300 (L/R/S/W).
Exam length: 100 questions
Time limit: Multi-component: USMLE Step 1 (~8 hr), Step 2 CK (~9 hr), OET Medicine (~3 hr per sitting), Pathway evaluation (varies)
Exam fee: $925 Pathways app + ~$1,065 Step 1 + ~$1,065 Step 2 CK + ~$587 OET Medicine + ECFMG application fee

Keys to Passing

Complete 500+ practice questions
Score 80%+ consistently before scheduling
Focus on highest-weighted sections
Use our AI tutor for tough concepts

ECFMG Certification Study Tips from Top Performers

1Plan the Step 1 to Step 2 CK transition. Step 1 is now pass/fail, so programs increasingly weight Step 2 CK numerical scores for screening. Most successful IMG candidates take Step 1 first (4-6 months dedicated, 400-600+ hours, using UWorld + First Aid + Pathoma + Sketchy), then immediately pivot to Step 2 CK (3-4 months, 300-500 hours, UWorld Step 2 + Online MedEd + AMBOSS). Target a Step 2 CK score >=240 to be competitive in most specialties; >=250 for competitive specialties (derm, ortho, rad-onc, plastics, ENT, ophtho).

2Tackle OET Medicine deliberately. ECFMG requires 350 on Listening, Reading, Speaking AND 300 on Writing in ONE sitting — you cannot combine. The Writing sub-test (single referral/discharge letter) is the most common failure point — practice the formal register, omit unnecessary clinical detail, organize by relevance to the reader (GP, specialist, allied health), include essential info only, and stay within 180-200 words. Use the official OET sample materials and a structured course (E2 OET, OET Academy) for at least 4-8 weeks of practice.

3Choose your Pathway early and execute. Pathway 1 (license-holders) is the most straightforward but applies only to clinicians with active or recent unrestricted licenses. Pathway 6 (ECFMG Mini-CEX with US-licensed physicians) is the default for most current students/recent grads from schools without an OSCE attestation. Start Mini-CEX scheduling at least 6-9 months before the Match deadline because finding 6 different US-licensed physician evaluators and completing all six clinical encounters takes time, money (~$200-$300 per Mini-CEX evaluator typically), and travel.

4Build USCE strategically. Aim for 2-3 hands-on US clinical rotations within 12-18 months of applying. Prioritize academic centers with formal IMG-friendly externship programs, the specialty you intend to apply for, and faculty who routinely write LORs for IMG residents. Avoid observership-only rotations as your only USCE. Get strong, specialty-specific LORs (3-4 total in ERAS) from US attendings who have supervised you in hands-on patient care. A US-issued LOR carries far more weight than a home-country LOR for IMG applications.

5Understand visa implications BEFORE the Match. J-1 (Exchange Visitor) is sponsored by ECFMG itself and is the most common for IMGs entering US residency — straightforward but carries a 2-year home-country residency requirement (waivable via Conrad 30 underserved-area service, federal interest waiver, or hardship). H-1B (specialty occupation) requires program sponsorship, passing USMLE Step 3 BEFORE the Match in some cases, and is more expensive for programs (so fewer programs offer it). Some IMGs prefer H-1B for flexibility; many programs only sponsor J-1. Research program-by-program visa sponsorship in FREIDA before applying.

Frequently Asked Questions

What is ECFMG Certification and who needs it?

ECFMG Certification is the credential issued by the Educational Commission for Foreign Medical Graduates (a division of Intealth) that confirms an international medical graduate (IMG) is ready to enter US graduate medical education. It is required to register for the NRMP Main Residency Match, to apply to ACGME-accredited residency programs through ERAS, and to obtain a J-1 visa sponsored by ECFMG. Once issued, ECFMG Certification is permanent and does not expire.

What are the requirements for ECFMG Certification?

Four requirements: (1) Medical Education — graduate (or be in final year) of a medical school listed in the World Directory of Medical Schools with an ECFMG Sponsor Note. (2) Medical Science Examinations — pass USMLE Step 1 (currently pass/fail) and USMLE Step 2 Clinical Knowledge (passing score 214). (3) Clinical Skills — complete one of six Pathways for ECFMG Certification. (4) Communication Skills — achieve minimum OET Medicine scores (350 on Listening, Reading, and Speaking; 300 on Writing) in one test administration.

What are the six Pathways for ECFMG Certification?

Pathway 1: applicants who currently hold or recently held a license to practice medicine. Pathway 2: school confirms a structured/objective clinical skills examination (OSCE Attestation required if final diploma not yet issued). Pathways 3, 4, and 5: medical school provides clinical-skills attestations via the Mini-Clinical Evaluation Exercise (Mini-CEX) reviewed by the dean. Pathway 6: ECFMG-administered Mini-CEX evaluated by licensed physicians across six clinical encounters. Applicants must apply in order (1->2->3->4->5->6); those who previously failed USMLE Step 2 CS may apply directly to Pathway 6. All Pathways require OET Medicine.

How much does ECFMG Certification cost in 2026?

Primary costs: 2026 Pathways application fee — $925 (deadline January 31, 2026 for 2026 Match eligibility). USMLE Step 1 fee — $1,065 (~$1,065). USMLE Step 2 CK fee — $1,065 plus international test delivery surcharge if testing outside the US. OET Medicine fee — approximately $587 (varies by country). Additional ECFMG application fees apply for the basic online application via myIntealth. Total typical cost is approximately $4,000-$5,000 not counting study materials, exam preparation, and travel.

What scores do I need on USMLE Steps and OET?

USMLE Step 1 is now pass/fail (no three-digit score; you must pass). USMLE Step 2 CK passing score is 214 (effective July 2024). OET Medicine requires a minimum of 350 on Listening, Reading, and Speaking sub-tests AND a minimum of 300 on Writing — all in ONE test administration (you cannot combine scores across sittings). A 350 maps to a B grade and 300 maps to a C+ in OET's banding.

When are the key 2026 ECFMG deadlines?

For the 2026 NRMP Match: Pathways application due January 31, 2026; ECFMG must receive OET Medicine scores directly from OET by January 31, 2026. ERAS opens for applicants in September 2025, programs begin reviewing applications in late September 2025, interview season runs October 2025 through January 2026, rank order list certification deadline is late February 2026, Match Day is mid-March 2026, and SOAP runs that same week for unmatched applicants. Confirm exact dates at ECFMG.org and NRMP.org.

Can I take USMLE Step 1 and Step 2 CK outside the US?

Yes. USMLE Step 1 and Step 2 CK are delivered at Prometric test centers worldwide. International testing carries an additional surcharge beyond the base $1,065 fee. Verify country availability and surcharge amounts at usmle.org/test-day. You must select your testing region during application and may change regions only within the eligibility period (with fee). USMLE Step 3 is currently delivered only in the US and US territories.

Do I need US Clinical Experience (USCE) for the Match?

USCE is not required by ECFMG for certification but is strongly preferred by most US residency programs. USCE includes observerships (no patient contact), externships (limited patient contact), clinical rotations during medical school via approved international electives, hands-on clerkships at US institutions, and post-graduate clinical experience. Programs typically value hands-on USCE in the past 1-2 years over older observerships. USCE letters of recommendation from US attendings are critical for competitive Match outcomes.