Difficulty is not just about the questions; it is about pass rates, the standard, and how well prepared each cohort is. Headline pass rates make exams look easier than they are for international graduates, because the reassuring numbers usually describe domestic students. Timing matters too, since sitting an exam at the wrong point in your training raises the difficulty for you specifically. Here is an honest comparison of difficulty and timing across the major pathways in 2026.
Key takeaways
- Headline pass rates usually report domestic graduates; IMG pass rates are markedly lower.
- The USMLE Step 1 is pass/fail; Step 2 CK carries the score that now matters most.
- PLAB 1 pass rates typically sit around 65 to 75 percent, with a paper-specific pass mark.
- Timing is part of difficulty: sit each exam at the right point in your training.
- Judge readiness with timed, exam-like assessments, not a running percentage.
What does "difficulty" actually mean here?
It means several things at once: the proportion who pass, the standard required, and the preparation each cohort brings. A useful way to read difficulty is by first-attempt pass rate, but only if you read the right cohort. The often-quoted high pass rates describe domestic graduates with built-in preparation infrastructure, while international graduates, assembling their own study plans with less clinical exposure and resource access, face a substantially harder task at the same exam. So the honest question is not "how hard is this exam" but "how hard is it for someone in my situation."
USMLE: pass/fail Step 1, high-stakes Step 2 CK
For the USMLE, first-attempt pass rates run around 91 to 96 percent for US MD students but around 72 to 75 percent for international graduates on Step 1, which is now pass/fail with a standard of 196 and requires roughly 60 percent correct. Step 2 CK sees around 96 to 98 percent for US and Canadian graduates but around 68 to 76 percent for IMGs, with the passing standard raised to 218 in July 2025. Since Step 1 went pass/fail, Step 2 CK carries the numeric weight for residency. Timing-wise, Step 1 typically follows the preclinical years with a dedicated block of about six to eight weeks, while Step 2 CK builds through clerkships with focused weeks before the exam. Our USMLE pass rates and difficulty guide goes deeper.
PLAB and the UKMLA: the UK route
PLAB 1 pass rates generally sit around 65 to 75 percent. It is 180 single-best-answer questions over three hours, with a paper-specific pass mark set by the Angoff method, historically around 110 to 118 out of 180, and candidates get up to four attempts. PLAB 2 is a practical OSCE sat in Manchester. Since 2024, PLAB content is aligned to the GMC's MLA content map, which is the same blueprint UK students meet in the UKMLA, sat around their final-year exams as the Applied Knowledge Test plus the Clinical and Professional Skills Assessment. A recurring difficulty for IMGs is the "most appropriate next step" question, which rewards the UK-standard first action rather than the most thorough one. Prep commonly runs one and a half to four months.
MCCQE and AMC: Canada and Australia
Canada's MCCQE Part I is the current computer-based written exam, with Part II historically suspended, so the written assessment is the focus; confirm current pass-rate data and format with the Medical Council of Canada. Australia's AMC MCQ is a computer-based test of 150 questions, with the pass standard rising slightly from 2026, and the pathway then moves into a supervised internship after a job offer; check current figures with the AMC. Both pathways reward several months of structured preparation, commonly three to twelve months, and both, like the others, are harder for candidates preparing at distance from the system they are entering.
Why the IMG gap matters more than the headline number
The gap between domestic and IMG pass rates, often around 20 points on the harder exams, is the single most important context missing from most difficulty discussions. It reflects structural factors, curriculum alignment, clinical exposure, language, and resource access, rather than ability. Practically, it means an IMG should plan against the IMG base rate, not the reassuring headline, and build in more preparation and closer alignment with the target system's guidelines and question style. Reading the wrong cohort's pass rate is how candidates underestimate the task.
How to judge your own readiness
Whatever the exam, judge readiness with timed, exam-like assessments taken under real conditions, not with a running question-bank percentage, which is a weak predictor. Sit the exam when your recent timed scores cluster above the standard with margin, at the right point in your training, rather than by a fixed calendar date. A tool that maps your actual weaknesses helps you get there faster. iatroX covers UK and international exams with semantic adaptive learning that targets the concepts you keep missing, at £29 per month or £99 per year with free sample questions. Try the free questions, and plan your budget with our exam prep costs by market.
Frequently asked questions
Which licensing exam is hardest? It depends on your cohort. For international graduates, the USMLE has the widest gap between IMG and domestic pass rates. Every major exam is substantially harder for candidates preparing away from the target system.
What is the PLAB 1 pass rate? Generally around 65 to 75 percent. The pass mark is set per paper by the Angoff method, historically around 110 to 118 out of 180, and candidates have up to four attempts.
Is USMLE Step 1 still scored? No. Step 1 is pass/fail with a standard of 196. Step 2 CK still reports a three-digit score and now carries the weight for residency, with a passing standard of 218 since July 2025.
When should I sit each exam? At the right point in training: USMLE Step 1 after preclinical years, Step 2 CK through and after clerkships, and PLAB or the AMC after graduation with focused preparation. Sit when your timed scores clear the standard with margin.
Do headline pass rates apply to IMGs? No. Headline rates usually describe domestic graduates. IMG pass rates are markedly lower, so plan against the IMG base rate for your exam.