Choosing a licensing route in 2026 is no longer just about which exam you can pass; it is about where the pathway actually leads. The UK, Australia, Canada, and US routes differ sharply on cost, timeline, and, crucially, on how realistic training access is once you have passed. This is an honest four-way comparison to help you match a route to your situation, not a pitch for any one country. Verify current fees and rules with each official body before committing, since several changed recently.
Key takeaways
- The four routes differ most on training access after the exam, not just on the exam itself.
- PLAB and the UKMLA are now the same standard, but UK training is prioritised for UK graduates.
- The AMC CAT is genuinely computer-adaptive and you must complete all 150 items.
- The MCCQE1 changed format and scale in 2025, and the numeric score feeds Canadian matching.
- The USMLE is the longest and most expensive route, with the highest earnings ceiling.
Why this comparison matters in 2026
Two things make this decision sharper than it used to be. First, the UK's Medical Training (Prioritisation) Act now prioritises UK graduates for training posts, which changes the value of the UK route for many IMGs, as we cover in what the Prioritisation Act changes. Second, several of these exams changed recently: the MCCQE1 was overhauled in 2025, the AMC lifted its pass standard slightly for 2026, and the USMLE raised the Step 2 CK bar and is changing its software. Choosing on old information is a real risk.
The routes at a glance
| Route | Exam format | Exam cost (approx) | After the exam | Training access |
|---|---|---|---|---|
| PLAB (UK) | PLAB 1: 180 SBAs, 3h. PLAB 2: OSCE | £283 + £1,036 | GMC registration, then NHS posts | Can apply, but offered after priority groups |
| AMC CAT (Australia) | 150 MCQs, 3.5h, adaptive | ~AUD 2,920 + AUD 642 account | Clinical exam or WBA, then AHPRA registration and internship | Generalist-friendly, strong demand |
| MCCQE1 (Canada) | ~230 MCQs, two sections, ~6.5h | ~CAD 1,500 | NAC OSCE, then CaRMS match | Very competitive for IMGs |
| USMLE (US) | 3 Steps, MCQ, multi-day | ~$675 to $900 per Step | ECFMG certification, then the Match | Competitive for non-US IMGs |
Confirm all figures with the awarding body, as fees and standards are revised regularly.
PLAB and the UKMLA
The UK route is the most affordable to enter and the most changed in what a pass now buys. From September 2026 all PLAB sittings are based on the updated 2026 MLA content map, so PLAB and the UKMLA are the same standard. The strength of the route is that GMC registration opens the large NHS locally employed and trust grade market, which the Prioritisation Act does not touch. The weakness is that training posts are now prioritised for UK graduates, so an IMG with no UK ties faces the least certain training payoff of any route here. Best for candidates with UK settlement or citizenship, or those wanting NHS service work.
AMC CAT
Australia's route is distinctive because its exam is genuinely computer-adaptive. The AMC CAT is 150 multiple-choice questions (130 scored, 20 unscored pilot items) over 3.5 hours, roughly 84 seconds each, scored on a 0 to 500 ability scale with a pass at 250, and delivered year-round through Pearson VUE worldwide. One rule matters more than any other: you must complete all 150 items, because an incomplete paper risks a "Fail, insufficient data to obtain result" outcome. Content is set in Australian practice, with PBS drug names and Therapeutic Guidelines management, so UK or US pattern answers can be traps. The strength is a relatively generalist exam and strong demand for doctors; the cost is substantial, around AUD 2,920 per authorisation plus the account fee, before the Clinical exam. Best for candidates who want a clear path into a health system with strong workforce demand.
MCCQE1
Canada's route changed materially in 2025, so old guides mislead. Since April 2025 the MCCQE1 is fully multiple-choice, about 230 questions in two sections over roughly six and a half hours, with the former Clinical Decision-Making cases removed. It is now scored on a 300 to 600 scale with a pass of 439 (mean 450, standard deviation 30), set in July 2025, and the old 100 to 400 scale with a pass of 226 is historical with no official crosswalk. The former MCCQE Part 2 was discontinued back in 2021, so Part 1 is the single qualifying exam. Critically, although your certificate says "pass", your numeric score is sent to the Canadian Resident Matching Service, and residency is very competitive for IMGs. Best for candidates prepared for a hard match and drawn specifically to Canada.
USMLE
The US route offers the highest ceiling and the highest cost. It is three Steps: Step 1 is pass/fail, Step 2 CK has a passing standard of 218 with a mean around 250, and Step 3 follows later. Registration for international candidates has moved to the USMLE's co-sponsors rather than the former ECFMG process, so confirm your route. The strengths are earning potential and the depth of training; the weaknesses are the length, the expense, and a Match that is genuinely competitive for non-US IMGs, where US clinical experience matters and the SOAP process backstops the unmatched. Best for candidates committed to the US, with time and budget, targeting realistic specialties.
Profile-based recommendations
Match the route to your circumstances. If you have UK settlement or citizenship, the UK route is efficient and training remains accessible to you. If you want a clear path into strong workforce demand and can absorb the cost, Australia is compelling. If you are set on Canada and ready for a hard match, the MCCQE1 is your exam, but plan around the IMG match gap. If you are committed to the US and have the time and money, the USMLE offers the highest ceiling. And if you are mobile and undecided, weigh training access and cost first, because the exam is the easy part; the pathway after it is where routes really differ.
The multi-exam hedge
One practical point for undecided candidates: you do not have to bet everything on one country before you are sure. iatroX covers UKMLA and PLAB, the AMC CAT, the MCCQE1, and the USMLE under one subscription, with content set in each exam's own clinical context and free sample questions to try, so you can prepare for, or compare, more than one route without buying separate banks. That is a hedge, not a recommendation to sit them all. You can start with the free questions.
Frequently asked questions
Which licensing route is cheapest? The UK PLAB route is the cheapest to enter, at roughly £1,300 for both parts, though training access for IMGs is now limited by the Prioritisation Act. The AMC CAT and USMLE are considerably more expensive.
Which exam is adaptive? The AMC CAT is genuinely computer-adaptive, adjusting difficulty to your performance, and you must complete all 150 items. PLAB, the MCCQE1, and USMLE Step 1 and Step 2 CK are linear, fixed-form exams.
What changed for the MCCQE1 in 2025? It became fully multiple-choice with the Clinical Decision-Making cases removed, moved to a 300 to 600 scale with a pass of 439, and shortened to about 6.5 hours. The old 226 pass on the 100 to 400 scale is historical.
Which route has the best training access for IMGs? It varies. Australia has strong workforce demand, while Canada and the US are very competitive for IMGs, and UK training is now prioritised for UK graduates. Weigh training access, not just the exam, when choosing.
Can one question bank cover several routes? Yes. iatroX covers UKMLA and PLAB, the AMC CAT, the MCCQE1, and the USMLE under one subscription with free sample questions, which is useful if you are comparing or hedging between routes.