Intealth ECFMG

Educational Commission for Foreign Medical Graduates

Pathway 6: Evaluation of Clinical Patient Encounters by Licensed Physicians


Who Should Apply


Pathway 6 is for applicants who do not meet the eligibility requirements for Pathway 1, 2, 3, 4, or 5.

To meet the requirements for Pathway 6, the applicant’s clinical skills must be evaluated by licensed physicians using ECFMG’s Mini-Clinical Evaluation Exercise (Mini-CEX) for Pathway 6.

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Eligibility Requirements


  • Applicant does not meet the eligibility requirements for Pathways 1-5.

In addition, to meet the requirements for Pathway 6:

  • Applicant’s clinical skills must be observed and evaluated by licensed physicians in six real, in-person clinical encounters using the ECFMG Mini-CEX for Pathway 6.
  • An electronic ECFMG Mini-CEX for Pathway 6 must be submitted to ECFMG for each clinical encounter by the evaluating physician through ECFMG’s Clinical Skills Evaluation and Attestation Portal.
  • For all six clinical encounters, applicant must obtain an acceptable score in each of the four clinical skills components evaluated using the Mini-CEX for Pathway 6: Medical Interviewing Skills, Physical Examination Skills, Professionalism/Communication Skills, and Clinical Reasoning & Judgment.

In addition to the requirements listed above, the applicant must meet the requirements in General Eligibility for All Pathways and Assessment of Communication Skills, Including English Language Proficiency, as well as all other eligibility requirements for ECFMG Certification.

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Criteria for Acceptable Physician Evaluators


To apply to Pathway 6, you will need to provide ECFMG with the names and e-mail addresses of licensed physicians who agree to observe and evaluate you during six distinct clinical encounters. Each physician may evaluate you on up to two encounters. This means that you will be required to identify a minimum of three and a maximum of six physicians in order to complete all six evaluations.

The physicians you select must:

  • Agree to directly observe and evaluate you during an in-person clinical encounter and provide an accurate assessment of your clinical skills to ECFMG using ECFMG’s Mini-CEX for Pathway 6.
  • Currently hold a full, unrestricted license to practice medicine without supervision in the jurisdiction where the clinical encounter will take place.
  • Have held a full, unrestricted license to practice medicine without supervision for a minimum of five years.
  • Give you approval to share their names and e-mail addresses with ECFMG.
  • Not be your relative. For the purposes of this evaluation, “relative” is defined as a spouse, child, grandchild, parent, grandparent, sibling, uncle, aunt, nephew, niece, and/or cousin.
  • Not be compensated by you to perform the evaluation.
  • Not be compensated by any third party to perform the evaluation other than what is provided as their salary or wage from the institution where they are employed and where the clinical encounter will take place.

You will be required to attest that each physician evaluator meets these criteria at the time you submit the physician’s information to ECFMG. It is your responsibility to ensure that all of your physician evaluators meet ECFMG’s criteria.

Note: Each physician evaluator will be able to submit evaluations for no more than 10 applicants for the 2023 Pathways season. If you select an evaluator who has already reached this limit, or if the evaluator has opted out of participating in the Mini-CEX process for Pathway 6, the on-line application system will indicate this when you enter the physician’s e-mail address, and you will be unable to request that physician as an evaluator.

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Criteria for Acceptable Clinical Encounters


Each of the six clinical encounters in which you are observed must:

  • Be a real, in-person clinical encounter. Telemedicine, virtual, and standardized patient encounters will not be accepted.
  • Take place in a formal clinical setting such as an outpatient office, an urgent care clinic, an emergency room, or a hospital.
  • Be primary care/general practice in nature and not subspecialized.
  • Focus on the diagnosis and treatment of acute and/or chronic illnesses in a primary care setting, such as general internal medicine, family medicine, pediatrics, or obstetrics and gynecology, in which each of the four components of the Mini-CEX (Medical Interviewing Skills, Physical Examination Skills, Professionalism/Communication Skills, Clinical Reasoning & Judgment) can be assessed.
  • Be one for which the patient has granted permission to be observed.
  • Occur after you submit your on-line application to Pathway 6 and after the physician evaluator has accepted your request for evaluation through the on-line application system.

In addition, please note that the encounter may be conducted in the language of the patient; however, the Mini-CEX evaluation must be submitted in English.

It is your responsibility to ensure that all of your clinical encounters meet these criteria.

In addition, you must take all steps necessary to ensure that each clinical encounter is conducted in compliance with all applicable licensure, regulatory, and/or legal requirements. You will be required to extend absolute immunity to ECFMG and indemnify and hold harmless ECFMG for any of your actions, intentional or otherwise, that are a part of the clinical encounter and the Mini-CEX assessment process.

You will be required to attest to this at the time you submit each physician’s information to ECFMG.

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ECFMG Mini-CEX for Pathway 6


The Mini-CEX is a well-studied workplace-based assessment tool used to evaluate an individual’s clinical skills in a variety of clinical settings. Using ECFMG’s Mini-CEX for Pathway 6, your physician evaluators will assess your clinical skills during real, in-person clinical encounters.

When completing the on-line Mini-CEX for Pathway 6, the physician evaluator will provide his or her name, physician license or registration number, and e-mail address, along with general information about the clinical encounter, including the date on which the encounter took place, the name of the health care facility at which the encounter took place, the setting of the encounter, the patient’s age, and the patient’s gender. The physician evaluator will then score your performance during the clinical encounter on each of four clinical skills components:

  • Medical Interviewing Skills
  • Physical Examination Skills
  • Professionalism/Communication Skills
  • Clinical Reasoning & Judgment

For each of the four components, the evaluator will score your performance on a scale of 1 to 9, with 1 being the lowest score and 9 being the highest score, based on the following anchors:

  • A score of 1, 2, or 3 to an applicant who performs like a medical student who is just beginning clinical experiences
  • A score of 4, 5, or 6 to an applicant who performs like an individual who has graduated from medical school
  • A score of 7, 8, or 9 to an applicant who performs like an individual who is or has been in the practice of medicine

The Mini-CEX for Pathway 6 also includes descriptions of the skills expected of an applicant who performs at the level of a medical school graduate ready to enter postgraduate training/graduate medical education (GME). Any score below this level will require the evaluator to provide a reason for the score.

For a sample Mini-CEX form, see the PDF version of the ECFMG Mini-CEX for Pathway 6. Please note that this sample version is for reference only; it should not be used to complete the evaluation or be submitted to ECFMG. All Mini-CEX responses must be collected and scored electronically through ECFMG’s Clinical Skills Evaluation and Attestation Portal. Paper evaluations and evaluations sent via e-mail will not be accepted.

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Scoring the Mini-CEX Evaluations


After ECFMG receives all six completed Mini-CEX evaluations for your application, ECFMG will determine your score in each of the four components evaluated (Medical Interviewing Skills, Physical Examination Skills, Professionalism/Communication Skills, and Clinical Reasoning & Judgment) by calculating the average score for each component across all six Mini-CEX evaluations.

If you do not meet ECFMG’s scoring requirements for the six Mini-CEX evaluations, the evaluations will automatically be provided to the Pathway 6 Review Committee for review. The Pathway 6 Review Committee is comprised of physician reviewers from ECFMG, FAIMER, and their Boards of Trustees. The Committee will determine whether you have met ECFMG’s clinical skills requirements for Pathway 6 based both on the scores and the reasons for the scores provided by your physician evaluators. If the decision of the Committee is that you have not met the requirements, you will be able to request a recheck of your Mini-CEX scores; instructions will be provided to you if applicable.

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Application Timing


If you meet the eligibility requirements for Pathway 6, you may apply using the on-line Application for Pathways for ECFMG Certification for 2023 Match.

Your application must be submitted no later than January 31, 2023.

In order for you to participate in the 2023 Match, ECFMG must determine the outcome of your Pathways application; determine your overall eligibility for the 2023 Match, including verifying your passing performance on USMLE Step 1 and Step 2 Clinical Knowledge (CK); then report your eligibility status to the National Resident Matching Program® (NRMP®) by the NRMP Rank Order List Certification deadline. ECFMG will not determine the outcome of your Pathways application until all required supporting documentation has been received and approved. Therefore, the time needed to complete the processing of your application is contingent upon receipt of all supporting documentation, including all six Mini-CEX evaluations from your physician evaluators. All six completed Mini-CEX evaluations must be received by ECFMG no later than February 15, 2023.

If you have not met all requirements for your Pathways application when the current application season ends, your application will be rejected and you will be required to reapply and pay any and all required application fee(s) in a future application season in order to meet the clinical and communication skills requirements for ECFMG Certification.

Please plan the timing of your application and clinical encounters accordingly.

Also, please note that you may not complete an in-person clinical encounter with a physician evaluator until after you submit your on-line application to Pathway 6 and after the physician evaluator has accepted your request for evaluation through the on-line application system. Physician evaluators will not be able to complete Mini-CEX evaluations for encounters that take place prior to when they accept the request for evaluation. You will be able to monitor the status of your requests through the Application for Pathways for ECFMG Certification for 2023 Match. See Completing the Mini-CEX Encounters and Evaluations below for more information.

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Application Instructions


  1. Confirm the eligibility of the three to six physicians who will observe and evaluate your clinical skills and obtain their approval to participate in the Mini-CEX process.
    • Confirm that each physician meets the Criteria for Acceptable Physician Evaluators (above).
    • Obtain each physician’s approval to evaluate your clinical skills using the Mini-CEX process.
    • Obtain each physician’s approval for you to provide his/her name and e-mail address to ECFMG.
    • Confirm the correct name and e-mail address that should be used for each physician evaluator.
  2. Access the Application for Pathways for ECFMG Certification for 2023 Match and determine general eligibility.
    • To begin the application, you will need to log in with your USMLE/ECFMG ID and ECFMG On-line Services password. Once you begin the application, you will have five days to complete and submit it. If the application is not submitted within five days, it will be deleted, and you will need to begin a new application if you wish to apply to a Pathway.
    • After you log in, the application will indicate whether you meet the eligibility requirements that pertain to all Pathways.
    • If you have failed Step 2 CS one or more times, the application will indicate that you will be required to apply to Pathway 6 and you will proceed directly to step 4 below.
  3. If you meet the general eligibility requirements for all the Pathways, you will proceed to questions regarding your eligibility for the specific Pathways.
    • You will begin by answering questions to determine your eligibility to apply to Pathway 1. If you do not meet the Pathway 1 eligibility requirements, the system will automatically determine your eligibility to apply to Pathway 2, 3, 4, or 5, based on the information in your ECFMG record.
    • If the system indicates that you are not eligible for Pathway 2, 3, 4, or 5, you will be required to apply to Pathway 6.
  4. Confirm that you have read and understand all requirements for Pathway 6. Before you submit your Pathway 6 application, you will be required to confirm that you have read all of the information on the Pathway 6 page on the ECFMG website, including Eligibility Requirements, Criteria for Acceptable Physician Evaluators, Criteria for Acceptable Clinical Encounters, and all Application Instructions, deadlines, and related information.
  5. Complete and submit the application. After providing the required information, you will be asked to certify your application, provide payment, and submit your application to ECFMG.
  6. Enter and manage information about your physician evaluators. After you submit your application, you will be able to enter the names and e-mail addresses of the physician evaluators for your six clinical encounters. See Managing Physician Evaluator Information and Tracking Encounters below for details.
  7. Be observed by your physician evaluators in six real, in-person clinical encounters. See Completing the Mini-CEX Encounters and Evaluations below for details.
  8. Ensure that your physician evaluators complete the on-line Mini-CEX evaluations through the ECFMG Clinical Skills Evaluation and Attestation Portal. Please note that it is your responsibility to ensure that your physician evaluators complete the Mini-CEX evaluations in support of your application; your application cannot be approved until all six completed Mini-CEX evaluations are received and accepted by ECFMG. All six Mini-CEX evaluations must be received by ECFMG no later than February 15, 2023.

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Managing Physician Evaluator Information and Tracking Encounters


After you submit your application to Pathway 6, you can enter and manage information about your physician evaluators and track the statuses of your clinical encounters through the Application for Pathways for ECFMG Certification for 2023 Match. The Application will display a Clinical Encounters Dashboard that lists entries for each of your six encounters. From the dashboard, you will be able to:

  • Add a physician evaluator for each clinical encounter.
    • You will need to provide the physician’s full name as it appears on the physician’s license/registration to practice medicine along with the physician’s e-mail address.
      • You must obtain the physician’s approval to provide this information before submitting it to ECFMG.
      • You should confirm with your physician evaluator the correct name and e-mail address to use before submitting them to ECFMG.
    • Only one physician evaluator may be entered for each encounter.
    • An individual physician may evaluate you on up to two encounters. If a physician will be observing you in two encounters, you will need to enter that physician’s information for both encounters.
    • Each physician evaluator will be able to submit evaluations for no more than 10 applicants for the 2023 Pathways season. If you select an evaluator that has already reached this limit, or if the evaluator has opted out of participating in the Mini-CEX process for Pathway 6, the on-line application system will indicate this when you enter the physician’s e-mail address, and you will be unable to request that physician as an evaluator.
    • When you add a physician evaluator, you will be required to certify a number of statements, including statements indicating that the physician meets the Criteria for Acceptable Physician Evaluators and that the encounter you will be observed in will meet the Criteria for Acceptable Clinical Encounters.
    • After you submit the information for a physician evaluator, the physician will receive an e-mail from ECFMG indicating that you have requested a Mini-CEX evaluation. The e-mail also will provide the physician with instructions on how to access ECFMG’s on-line Clinical Skills Evaluation and Attestation Portal in order to accept or reject your request and complete the Mini-CEX evaluation.
  • Remove a physician evaluator from an encounter.
    • You can remove a physician from an encounter if any of the following are true:
      • The physician has not accepted your request for a Mini-CEX evaluation.
      • The physician rejects your request. If a physician evaluator rejects your request for a Mini-CEX evaluation, you will be notified by e-mail. If your request is rejected, you will need to remove that physician from the encounter and add a new one in order to move forward with that Mini-CEX encounter. Note that a physician evaluator may reject a request before or after accepting a request.
      • The physician does not accept your request within 15 days of when you submit it. If the physician does not accept the request within 15 days of when you submit it, the request will be automatically withdrawn, and you will be notified by e-mail. If the request is automatically withdrawn, you will need to remove that physician from the encounter and add a new one, or re-enter the physician’s information if you expect the physician to accept your request, in order to move forward with that Mini-CEX encounter.
      • The physician accepts your request but does not complete the Mini-CEX evaluation within 15 days. If a physician evaluator accepts your request but does not complete the Mini-CEX and submit the evaluation within 15 days of accepting the request, the request will be automatically withdrawn, and you will be notified by e-mail. If the request is automatically withdrawn, you will need to remove that physician from the encounter and add a new one, or re-enter the physician’s information if you expect the physician to complete the encounter, in order to move forward with that Mini-CEX encounter.
    • You will be unable to remove a physician from an encounter if either of the following is true:
      • The physician has accepted your request and it has not been subsequently rejected by the physician or automatically withdrawn.
      • The encounter has been completed and the physician evaluator has submitted the Mini-CEX evaluation to ECFMG through the Clinical Skills Evaluation and Attestation Portal.
    • When you remove a physician from an encounter:
      • You will be required to confirm that the encounter did not take place.
      • The physician will be notified by e-mail that you have withdrawn your request for evaluation.
  • View the statuses of your six encounters. You will be able to view whether the request for each encounter is accepted or rejected, or whether the encounter has been completed. Completed encounters are those that have taken place and for which the Mini-CEX evaluation has been submitted by the physician evaluator through the Clinical Skills Evaluation and Attestation Portal.
    • Your physician evaluator must accept your request through the Clinical Skills Evaluation and Attestation Portal before the encounter takes place. Physician evaluators will not be able to complete Mini-CEX evaluations for encounters that take place prior to when they accept the request for evaluation. Track the status of your requests to ensure they are accepted prior to completing the encounter.
  • View a list of physician evaluators that have been removed from encounters.

In addition, please note the following regarding requests for evaluation:

  • If you need to edit or change the name or e-mail address of a physician evaluator that you have already entered, you will first need to remove the physician from the encounter, then add the physician to the encounter again with the correct information.
  • A history of all your requests will be retained by ECFMG.

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Completing the Mini-CEX Encounters and Evaluations


When you add a physician evaluator for an encounter through the Application for Pathways for ECFMG Certification for 2023 Match, the physician will receive an e-mail from ECFMG indicating that you have requested a Mini-CEX evaluation. The e-mail also will provide the physician with instructions on how to access ECFMG’s on-line Clinical Skills Evaluation and Attestation Portal. The Clinical Skills Evaluation and Attestation Portal is where the physician can accept or reject your request for evaluation before the clinical encounter takes place, and submit the Mini-CEX evaluation after the clinical encounter takes place. Access to this portal will require that the physician enter the same e-mail address that you entered when you added the physician’s information to the Clinical Encounters Dashboard in the Application for Pathways for ECFMG Certification for 2023 Match, so it is essential that you confirm the correct e-mail address to use with the physician before submitting it.

After logging into the Clinical Skills Evaluation and Attestation Portal, the physician can accept or reject your request for evaluation. The physician must accept your request through the portal prior to the clinical encounter taking place. You can monitor the status of requests on the Clinical Encounter Dashboard in your Pathways application.

  • If the physician rejects your request:
    • You will be notified by e-mail.
    • You will need to remove the physician from the encounter and add a new physician to complete the Mini-CEX.
  • If the physician accepts your request:
    • The physician will be required to attest to statements about the encounter, including a statement indicating that s/he meets the Criteria for Acceptable Physician Evaluators.
    • You will have 15 days to work with the physician evaluator to:
      • Arrange for an appropriate in-person clinical encounter,
      • Complete the encounter, and
      • Ensure that the physician evaluator submits his/her evaluation of your clinical skills as demonstrated during the encounter through the Clinical Skills Evaluation and Attestation Portal.
    • You will be unable to remove the physician from the encounter unless either:
      • The physician subsequently rejects your request, or
      • The physician does not submit the Mini-CEX evaluation within 15 days of when the request was accepted.

Important Note: Clinical encounters must not take place until after the physician evaluator accepts your request for evaluation. You can monitor the status of requests on the Clinical Encounter Dashboard in your Pathways application.

During the clinical encounter, the evaluator will observe you interacting with a patient. You must perform a medical interview and an appropriate physical examination of the patient. At the completion of the encounter, you should summarize the patient’s clinical findings in a brief (less than five minutes) presentation that includes an appropriate differential diagnosis and a plan for the next steps for diagnosis and treatment.

After observing your clinical interaction with the patient and your presentation, the physician evaluator must log in to the Clinical Skills Evaluation and Attestation Portal and complete and submit the Mini-CEX evaluation based on his/her observations of your clinical skills as demonstrated during the encounter. See ECFMG Mini-CEX for Pathway 6 and Scoring the Mini-CEX Evaluations above for details on how performance is evaluated and scored.

After the evaluator submits the Mini-CEX evaluation, the status for the encounter will be updated on the Clinical Encounters Dashboard in the Application for Pathways for ECFMG Certification for 2023 Match; however, the evaluation and scores will not be made available to you. In addition, the evaluator will be advised not to share the evaluation and scores with you.

All Mini-CEX encounters must be completed through the process outlined above, and all Mini-CEX evaluations must be completed through the Clinical Skills Evaluation and Attestation Portal. ECFMG will not accept Mini-CEX evaluations submitted outside of the Clinical Skills Evaluation and Attestation Portal in any way, including by e-mail.

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Fees and Payment


The fee for applying to a Pathway is $925. Full payment is due when you submit your application. If the application is not submitted within five days of when you begin it, it will be deleted, and you will need to begin a new application if you wish to apply to a Pathway.

You must use a Visa, MasterCard, Discover, or American Express credit card with a security code; credit available in your ECFMG Financial Account cannot be used to pay for a Pathways application.

Fees related to your application are not refundable. If you submit a Pathways application and ECFMG determines that you are ineligible for the Pathway, your application will be rejected and the fee will not be refunded. In addition, if ECFMG does not receive all required documentation in support of your application, as well as any required verifications of submitted documentation from the issuing authority, your application will not be complete, and the application fee will not be refunded.

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Application Processing Time


Once your application has been submitted, you can use the on-line Application for Pathways for ECFMG Certification for 2023 Match to check the status of your application. The following guidelines may be helpful:

  • Please allow five business days after submission of your application for a case manager to begin reviewing your application.
  • The status of each of your Mini-CEX evaluations will be reflected in your application.
  • Once your eligibility review has been completed, ECFMG will conduct a final review of your application. Please allow five business days for this final review.
  • If review of your Mini-CEX evaluations is required by the Pathway 6 Review Committee, you will be notified by e-mail of the timeline for completion of the review.

The time needed to complete the processing of your application is contingent upon receipt of all six Mini-CEX evaluations.

The preceding information is current as of May 12, 2022 and is subject to change. Please visit the ECFMG website frequently for updates regarding these requirements.

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[Last update: May 12, 2022]

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