Pathway 6 Mini-CEX Guide: Complete 2027 Workflow

Pathway 6 Mini-CEX at a glance

ECFMG Pathway 6 requires six distinct, real, in-person clinical encounters. In every encounter, a qualified physician directly observes the applicant interview and physically examine a real outpatient, listens to a brief case presentation, and submits an independent electronic evaluation.

The six encounters are not retrospective attestations of ordinary clinical experience. Each encounter must occur after the 2027 Pathway 6 application is submitted and after the assigned physician accepts that encounter's request through ECFMG's Clinical Skills Evaluation and Attestation Portal.

The applicant needs three to six evaluators because one physician may assess no more than two encounters. All six evaluations must be received by February 15, 2027. The Pathways application itself is due January 31, 2027, Eastern Time.

The Mini-CEX assesses four domains: Medical Interviewing Skills, Physical Examination Skills, Professionalism/Communication Skills, and Clinical Reasoning and Judgment. ECFMG averages each domain separately across the six encounters.

The safest strategy is compliance-first: verify the person, setting, patient, legal authority, request status, encounter content, and electronic submission for each slot. A clinically impressive encounter that violates one structural rule does not qualify.

Confirm that Pathway 6 is actually your route

Pathway 6 is for applicants who do not meet eligibility for Pathway 1, 2, 3, 4, or 5. It also is mandatory for anyone who failed Step 2 CS one or more times, even if licensure or school facts otherwise fit another route.

An applicant with a Step 2 CS pass that remains valid for ECFMG Certification is not eligible for a Pathway because the clinical skills requirement has already been met. An applicant eligible for Pathway 1 must use Pathway 1 unless the Step 2 CS failure override applies.

MyIntealth determines school-based Pathway 2–5 eligibility from the applicant's record after Pathway 1 questions. You cannot select Pathway 6 merely because arranging evaluators appears preferable to obtaining a school attestation.

General eligibility also requires an Application for ECFMG Certification with Accepted or Pending Credential Verification status, no bar to certification, and no prior satisfaction of the clinical and communication skills requirements.

The $945 application fee is nonrefundable if ECFMG determines the route is ineligible. Resolve conflicting examination, school, graduation, or license data before certifying the application.

• Step 2 CS failure: Pathway 6 mandatory.
• No Step 2 CS failure and eligible recent unsupervised licensure: Pathway 1 mandatory.
• No Pathway 1: system checks Pathways 2–5.
• No Pathways 1–5: Pathway 6.
• Still-valid Step 2 CS pass: no Pathway.

Build the evaluator pool before starting the application

You cannot perform an eligible encounter before submitting the application and receiving evaluator acceptance, but you can—and should—identify lawful settings and screen willing physicians first.

Start with real professional relationships in settings where you are already legally permitted to participate: current or former clinical supervisors, faculty, physicians in your medical school's outpatient system, or physicians in an institution that has formally authorized your patient-contact role. ECFMG does not require the encounters to occur in the United States.

A U.S. observership is not automatically useful. If the institution prohibits you from interviewing or physically examining patients, the encounters cannot qualify. By contrast, a lawful outpatient role in another country can qualify when every evaluator and encounter rule is satisfied.

Use institutional leadership where needed. The evaluator's personal willingness does not override clinic policy, patient-consent processes, privacy rules, insurance requirements, scope-of-practice law, or local regulation.

Create more potential relationships than the minimum. Three physicians can cover six encounters, but one rejection, license issue, illness, or clinic cancellation can stop the schedule. A reserve evaluator should be fully pre-screened, not entered simultaneously into an occupied encounter slot.

The complete evaluator eligibility audit

An acceptable evaluator currently holds a full, unrestricted license to practice medicine without supervision in the jurisdiction where the encounter occurs. The physician also must have held a full, unrestricted license for at least five years.

Check both current status and history through the official regulator when a public lookup exists. A training, provisional-with-supervision, restricted, expired, or wrong-jurisdiction license does not satisfy the current-license rule.

The evaluator must agree to observe the applicant directly during the in-person encounter, including the interview and physical examination, listen to the presentation of history, physical, assessment, and plan, and submit an accurate assessment through the portal.

The physician cannot be the applicant's spouse, child, grandchild, parent, grandparent, sibling, uncle, aunt, nephew, niece, or cousin. A physician may evaluate a maximum of two encounters for one applicant and may serve up to 10 applicants during the 2027 season.

The applicant cannot pay the physician for evaluating. A third party also cannot pay the evaluator for the evaluation except ordinary salary or wages from the institution where the physician is employed and the encounter takes place.

ECFMG's current page contains a specific notice that it will not accept evaluations from students of Gold USMLE, Platinum USMLE, or successor corporations, or evaluators known to be associated with the named organizations and individual in that notice. Read the live notice before committing to any arrangement.

A professional evaluator outreach message

The first request should explain the work and allow an easy refusal. Do not ask for a favorable score. Do not imply that the physician is only confirming attendance. Ask for permission before giving the physician's name and email to ECFMG.

Adapt the template below to an existing professional relationship and the institution's rules. An unsolicited message cannot create lawful patient access; clinic permission and an eligible role still must exist.

• Subject: Request to serve as an ECFMG Pathway 6 Mini-CEX evaluator
• Dr. [Name], I am applying through ECFMG Pathway 6 and am seeking a qualified physician to directly observe one or two real outpatient encounters.
• The process requires you to hold a current full unrestricted license in the encounter jurisdiction and to have held full licensure for at least five years.
• For each encounter, you would accept an electronic ECFMG request before the visit, observe my interview and physical examination, listen to a brief presentation, and submit an independent electronic evaluation within 15 days.
• The encounter must be a lawful primary-care/general-practice outpatient visit with patient permission. ECFMG prohibits applicant payment for the evaluation.
• Would you be willing to review ECFMG's physician instructions and consider participating? If so, may I share your licensed name and preferred email with ECFMG?
• I understand if your schedule, institutional policy, or eligibility does not permit participation.

Qualifying encounter settings

Every Mini-CEX must take place in a formal outpatient clinical setting with a registered outpatient. ECFMG accepts routine and sick outpatient-office visits when the remaining criteria are met.

The visit must be primary care or general practice in nature and focus on diagnosis and treatment of an acute or chronic illness. It cannot be subspecialized. General internal medicine, family medicine, pediatrics, and obstetrics and gynecology are examples, not automatic approvals.

A specialized physician may evaluate if the physician qualifies, but the encounter itself still must be general. A neurologist observing a genuinely general outpatient encounter may qualify; a narrowly subspecialized neurology follow-up does not become general because the physician also treats primary-care problems elsewhere.

Emergency-room, separate dedicated urgent-care, inpatient, telemedicine, virtual, standardized-patient, home-visit, and informal-location encounters are excluded.

The applicant must be permitted under all applicable legal, regulatory, licensing, and institutional rules to interview and physically examine the patient. ECFMG's process is not itself authorization to touch a patient.

Patient eligibility, consent, and privacy

The patient must be real, registered as an outpatient, and not a relative of the applicant under the same family definition ECFMG uses for evaluators. A standardized patient, colleague role-playing a patient, or family member does not qualify.

The patient—or the parent or guardian in a pediatric visit—must grant permission to be interviewed and examined. Use the institution's approved consent process and explain the applicant's role accurately. Consent is not meaningful if the patient believes the applicant is the treating licensed physician when that is not true.

A qualifying Mini-CEX requires an appropriate physical examination. Choose encounters where the patient is comfortable with direct observation and where the necessary examination falls within the applicant's legal role and competence.

The evaluator submits age, gender, date, facility, and encounter-setting information in the portal. Applicants should not create a private spreadsheet containing names, diagnoses, medical-record numbers, or other unnecessary protected health information. Track operational status with nonidentifying slot labels.

The encounter may be conducted in the patient's language, while the evaluation must be submitted in English. Use an interpreter when clinically and institutionally required; do not sacrifice safe communication merely to simplify the assessment.

Outside the United States: equally valid when compliant

ECFMG's FAQ explicitly allows Pathway 6 encounters outside the United States and states that U.S. location confers neither advantage nor disadvantage for meeting the Pathway requirements.

The evaluator's qualifying license must cover the jurisdiction where the encounter occurs. The applicant also must be permitted there to interview and physically examine patients. A physician licensed only in another country cannot supervise a local encounter solely based on experience.

Location also does not change the general-outpatient, real-patient, consent, compensation, request-timing, scoring, or electronic-submission rules. The evaluation must be completed in English even when the encounter uses another language.

Do not confuse Pathway eligibility with how residency programs interpret U.S. clinical experience. ECFMG says it does not disclose the encounter country or other Mini-CEX details to residency programs. A Pathway 6 encounter is certification evidence; it is not automatically USCE, an ERAS experience, or a U.S. letter of recommendation.

Portal setup: enter the evaluator exactly

After submitting the Pathway 6 application, the Clinical Encounters Dashboard provides six encounter slots. Only one evaluator can occupy a slot at a time.

Enter the physician's full name as it appears on the license and the exact email the physician will use to access the Clinical Skills Evaluation and Attestation Portal. Obtain permission before sharing both.

On first login, the evaluator completes a profile that includes licensed name, date of birth, USMLE ID and MyIntealth ID if applicable, licensing authority names, and license or registration numbers. A mismatched email can prevent access.

If one physician will evaluate two encounters, create two separate requests. The physician must accept or reject each individually, and each encounter has its own timing and submission status.

If you entered the wrong name or email and the request is still removable, remove the evaluator and re-add the correct information. ECFMG retains request history.

The two 15-day clocks

Clock one begins when the applicant sends the request. The evaluator has 15 days to log in and accept. If no acceptance occurs, the request is automatically rejected or withdrawn in the system, and the applicant must remove and replace the physician or send a new request.

Clock two begins at acceptance. Within the next 15 days, the applicant and physician must arrange a qualifying encounter, complete it, and ensure the physician submits the electronic Mini-CEX.

If the physician observed an encounter during the second window but failed to submit before expiration, the old encounter cannot be rescued with a new request. The evaluator must accept a new request and observe a new clinical encounter.

There is no separately published required number of minutes for the individual encounter. The visit still must be clinically real and long enough for an appropriate interview, physical examination, and assessment of all four domains. The case presentation itself should be less than five minutes.

Do not send all six requests merely because evaluators have agreed in principle. Coordinate acceptance with actual eligible patient access so the second clock does not run out.

When an evaluator can be removed or replaced

Before acceptance, the applicant can withdraw an evaluator request. After acceptance, the applicant generally cannot withdraw it while active, although the evaluator can reject it.

If the physician rejects, the applicant receives notice and can remove the physician from that slot. The applicant is not given the evaluator's reason for rejection.

Automatic rejection or withdrawal after either 15-day deadline also permits the applicant to remove the physician and add a replacement or resend to the same physician when appropriate.

An evaluator cannot be removed after the completed electronic evaluation is submitted. When removing a physician from an eligible unfinished slot, the applicant must confirm the encounter did not occur, and the physician is notified.

Ask an unavailable evaluator to reject promptly instead of allowing a slot to remain locked. Keep a reserve plan, but never perform an encounter for a replacement before that replacement accepts the new request.

What happens during the Mini-CEX

The evaluator should observe the entire encounter. The applicant conducts an organized, problem-focused medical interview, performs an appropriate physical examination, and demonstrates professional patient communication throughout.

At the end, the applicant delivers a brief presentation of less than five minutes. It should include the key history and examination findings, a prioritized assessment or differential diagnosis, and reasonable next diagnostic and treatment steps.

The visit remains patient care, not theater. Follow infection control, hand hygiene, draping, chaperone, trauma-informed care, interpreter, allergy, and escalation policies. Do not perform a maneuver solely to display technique when it is not clinically indicated.

The evaluator then enters the date, outpatient facility, setting, patient age and gender, four scores, and an observation-based reason for each score in the portal. The applicant does not complete or handle the evaluation.

Domain 1: Medical Interviewing Skills

ECFMG's sample rubric expects a medical-school graduate to facilitate accurate history collection, use questions and direction effectively to obtain needed information, and produce an organized and accurate history.

Begin broadly enough to hear the patient's concern, then narrow deliberately. Establish chronology, severity, modifying factors, associated symptoms, relevant past history, medications, allergies, exposures, family and social context, and review of systems only as clinically relevant.

Good organization is visible in transitions and summaries. A memorized checklist that ignores the patient's answer can appear less competent than a shorter, hypothesis-driven interview.

Practice retrieving red flags without becoming alarmist, clarifying ambiguous words, and reconciling contradictions. Before moving to the examination, summarize the story and invite correction.

Common weaknesses include interrupting too early, asking stacked questions, collecting unrelated detail, omitting medication/allergy information, failing to explore the patient's perspective, or presenting a history the patient would not recognize.

• Open question, then focused clarification.
• Chronology and symptom characterization.
• Relevant context, risks, medications, allergies, and red flags.
• Patient ideas, concerns, expectations, and functional effect when relevant.
• Organized summaries and accuracy checks.
• No invented negative findings.

Domain 2: Physical Examination Skills

The official rubric expects an efficient, logical sequence, an examination focused on the patient's problem or presentation, and sensitivity to modesty and comfort.

An appropriate examination is not necessarily a complete head-to-toe examination. State what you are doing, obtain permission, wash or sanitize hands, expose only what is necessary, use a chaperone under clinic policy, and perform relevant maneuvers in a coherent order.

Technique matters, but selection matters too. The examiner should be able to see that the physical is driven by the history and differential. Add focused systems needed to test dangerous or likely alternatives.

Respond to pain, limited mobility, cultural needs, and signs of distress. Stop or modify a maneuver when clinically appropriate. Patient safety and dignity are part of competent examination, not separate from it.

Practice with direct observation before the formal encounters. Ask a qualified clinician to identify inefficient sequencing, poor positioning, inaudible instructions, missed hand hygiene, inadequate exposure, or maneuvers that do not answer a clinical question.

• Hand hygiene and role-appropriate consent.
• Focused, hypothesis-driven selection.
• Efficient logical sequence.
• Correct positioning and technique.
• Modesty, comfort, chaperone, and pain awareness.
• No unsafe, unnecessary, or unauthorized maneuver.

Domain 3: Professionalism and Communication

ECFMG's sample rubric expects respect, compassion, empathy, trust, and an appropriate response to nonverbal cues.

Introduce yourself accurately. Do not imply licensure, resident status, or treating authority you do not hold. Explain the evaluator's presence and the purpose of direct observation in language the patient can understand under institutional policy.

Listen without rushing, use plain language, acknowledge emotion, and check comprehension. Notice hesitation, discomfort, hearing or language barriers, low health literacy, and disagreement.

Protect privacy and dignity. Do not discuss the evaluation score in front of the patient, turn the encounter into a performance, or continue after consent is withdrawn.

Trust also depends on reliability: accurate statements, no fabricated findings, appropriate uncertainty, and timely escalation to the supervising physician when the patient needs urgent care.

• Accurate introduction and role.
• Respectful consent and shared agenda.
• Empathy and response to nonverbal cues.
• Clear, jargon-limited explanations.
• Privacy, modesty, and cultural humility.
• Honest limits and appropriate escalation.

Domain 4: Clinical Reasoning and Judgment

The official graduate-level expectation focuses on an efficient oral presentation of the patient's problems, including differential diagnoses and recommendations for next steps.

Build the problem representation before listing diagnoses: patient context, time course, key syndrome, and discriminating positives and negatives. Rank the differential by likelihood and danger rather than reciting an unprioritized list.

Link each proposed test or action to a question. Include urgent exclusions, outpatient safety, medication risks, follow-up, and escalation when relevant. Stay within the information actually obtained.

The presentation must be less than five minutes. Use a consistent structure: one-line identification and concern, concise history, focused exam, problem representation, prioritized differential, and plan.

Clinical judgment includes recognizing uncertainty. A safe, explicit plan to obtain more information can be stronger than false certainty. Do not claim to have reviewed tests or records you did not see.

How the 1–9 scoring system works

The evaluator selects one score from 1 to 9 for each of the four domains based only on observed performance in that encounter—not on the applicant's CV, current title, or years since graduation.

ECFMG groups 1–3 as performance like a medical student beginning clinical experiences, 4–6 as performance like a medical school graduate, and 7–9 as performance like an experienced or practicing physician. The evaluator must add information explaining what was observed for each score.

After all six evaluations are received, ECFMG calculates four separate averages: one average for each domain across the six encounters. A high interviewing score does not mathematically replace a weak physical-examination domain because the components are assessed separately.

ECFMG's public page does not publish a simple guaranteed pass number. If its scoring requirements are not met, all six evaluations automatically go to the Pathway 6 Review Committee. The Committee considers scores and evaluators' reasons and may contact evaluators.

If the Committee concludes the requirement was not met, ECFMG says the applicant can request a recheck of Mini-CEX scores using instructions provided when applicable. A recheck is not described as a new clinical performance assessment.

Why six observations are used

The Mini-CEX is a workplace-based direct-observation tool. One patient, one observer, and one clinical problem provide only a narrow sample of performance. Multiple encounters broaden the evidence.

Published medical-education reviews support the Mini-CEX as a structured method with reasonable validity, reliability, and educational utility, while also showing that results depend on sampling and implementation. That background helps explain why ECFMG requires six encounters and averages domains across them.

Do not import a cutoff or reliability estimate from a different study into ECFMG's Pathway. Research instruments vary in setting, trainees, raters, scoring, and number of observations. ECFMG's 2027 rules—not a journal article—control certification.

Practically, treat every encounter as an independent performance. Do not rely on one evaluator to compensate for another or ask evaluators to coordinate scores.

A four-week preparation plan

Preparation should improve real clinical behavior, not rehearse a deceptive encounter. Use simulated cases and legitimate supervised practice before the six formal observations.

Week 1: download the official sample rubric, baseline yourself in each domain, and have a qualified clinician directly observe a complete mock encounter. Identify two high-impact behaviors per domain.

Week 2: practice focused histories and examinations across common outpatient presentations. Require every case to end with a concise problem representation, prioritized differential, and plan.

Week 3: add time pressure and patient-centered complexity—interpreters, medication reconciliation, chronic disease, uncertainty, emotional cues, and safety-net instructions. Continue external observation.

Week 4: rehearse the exact workflow without rehearsing the patient. Practice role introduction, permission, infection control, focused physicals, and under-five-minute oral presentations. Confirm evaluator and setting compliance separately.

Do not use formal patient encounters as your first direct-observation feedback. Because the applicant will not see scores or comments, formative coaching should happen before the portal requests.

Day-of-encounter checklist

Confirm compliance before seeing the patient. If the portal request is not accepted, the setting changed to an excluded location, your patient-contact permission is unclear, or the evaluator cannot observe the entire interaction, do not count that visit as the Mini-CEX.

Clinical care takes priority. If the patient becomes unstable, requires privacy without an observer, or withdraws permission, follow the treating team's process and arrange a different assessment encounter.

• Pathway 6 application was submitted.
• Correct evaluator accepted the correct encounter request.
• Encounter falls within the evaluator's 15-day submission window.
• Evaluator license, five-year history, relationship, and compensation remain compliant.
• Patient is a registered outpatient in a formal setting.
• Visit is primary care/general practice, not subspecialized.
• Applicant is legally and institutionally permitted to interview and examine.
• Patient or guardian gave permission.
• Evaluator can directly observe the full interview and physical.
• Applicant has hand hygiene, equipment, chaperone, and interpreter support as needed.
• Applicant will deliver the under-five-minute presentation.
• Evaluator knows the electronic submission deadline.
• No personal record will contain unnecessary patient identifiers.

After the encounter: completion is an electronic status

The evaluator—not the applicant—logs into ECFMG's portal and submits the evaluation. The sample PDF is for reference only. Paper forms and emailed evaluations are not accepted.

The dashboard changes the encounter to completed when the encounter occurred and the Mini-CEX was submitted. The applicant cannot see the evaluation or scores, and the evaluator is instructed not to share them.

Send a neutral operational reminder if needed: confirm the portal deadline and offer ECFMG's evaluator-support contact. Do not ask how the physician scored you, suggest a score, or ask the evaluator to revise independent observations.

If the 15-day post-acceptance window expires without submission, a new request does not revive the old patient encounter. The applicant needs a newly accepted request and a new encounter.

Do not stop at six verbal confirmations. All six dashboard slots must show completion, and ECFMG must receive and accept all evaluations.

What ECFMG and residency programs will see

The applicant sees request and completion statuses, not scores or evaluator comments. The confidentiality is deliberate: the evaluator provides an independent assessment to ECFMG.

ECFMG's FAQ states that Mini-CEX scores, comments, encounter country, and other evaluation details are not shared with third parties, including residency programs.

An ECFMG report confirms only whether the applicant has met Pathway requirements once the Pathways application is accepted. Do not list an invented score on ERAS or ask an evaluator to create a separate score report.

A physician may independently know you well enough to write a legitimate residency letter based on a broader clinical relationship, but the Mini-CEX evaluation itself is not an ERAS Letter of Recommendation and ECFMG does not transmit it as one.

Deadline and processing plan for the 2027 Match

Submit the 2027 Pathways application by January 31, 2027, Eastern Time. All six electronic Mini-CEX evaluations must be received by February 15, 2027.

The NRMP Rank Order List deadline is March 3, 2027, at 9:00 p.m. Eastern Time. ECFMG must determine the Pathway outcome, assess overall exam eligibility including Step 1 and Step 2 CK, and report the status to NRMP.

ECFMG advises allowing five business days after Pathway 6 submission for a case manager to begin review and five business days for final review after eligibility review. Review Committee cases take additional time communicated by email.

OET Medicine is also required. For the 2027 Pathways, all four minimums must come from one administration taken on or after January 1, 2025: 350 in Listening, Reading, and Speaking and 300 in Writing. ECFMG recommends testing no later than the final scheduled date in December 2026, but earlier protects a retake.

A February 15 Mini-CEX deadline is not a sensible completion goal. Build time for withdrawn requests, new patients, evaluator illness, status problems, ECFMG review, and NRMP transmission.

Reapplicants must complete six new encounters

A prior-season Mini-CEX cannot be reused for the 2027 Pathways. ECFMG requires six new encounters after the new application and after each new evaluator request is accepted.

An evaluator from the earlier season may potentially participate again if the physician still meets every 2027 criterion, remains under the season limit, and observes a new eligible encounter through the new portal workflow.

Do not assume that an accepted Pathway must be repeated every year. A 2027 Pathway expires December 31, 2029. Reapplication is relevant when a prior application was not completed or when an expired/expiring Pathway must be revalidated under current rules.

If revalidating, MyIntealth directs an eligible applicant to Pathway 1 and otherwise Pathway 6. Confirm the current revalidation rules rather than reusing an old checklist.

Irregular behavior and paid-evaluation risk

ECFMG requires both applicant and evaluator attestations. False evaluator qualifications, fabricated patients, retrospective encounters, paid signatures, altered documentation, or other attempts to subvert the process can trigger rejection and irregular-behavior proceedings.

ECFMG's policies list falsified Mini-CEX documentation among representative irregular-behavior examples and describe potentially lasting consequences, including a permanent annotation and bars from certification services.

Do not let an agency's marketing language replace the live ECFMG rules. Verify the physician, institution, encounter, compensation structure, and current exclusion notice yourself.

A legitimate institutional program may charge for education, administration, or clinical access under its own lawful policies, but no label cures prohibited payment to the evaluator for performing the evaluation. When the arrangement is ambiguous, obtain clarification from ECFMG before proceeding.

Common mistakes

• Beginning encounters before the Pathway 6 application is submitted.
• Performing an encounter before the specific evaluator accepts the specific request.
• Assuming a U.S. location is required or provides ECFMG scoring advantage.
• Using a physician with the wrong license jurisdiction or fewer than five years of full licensure.
• Using more than two encounters with one evaluator.
• Forgetting that two encounters with one physician require two requests.
• Paying a physician or allowing a separate third party evaluator payment.
• Using a prohibited commercial arrangement or association named in ECFMG's current notice.
• Using a relative as evaluator or patient.
• Using a subspecialty, emergency, urgent-care, inpatient, home, telemedicine, virtual, or standardized-patient encounter.
• Assuming an observership permits physical examination.
• Failing to obtain patient or guardian permission.
• Allowing the 15-day acceptance window to expire.
• Allowing the 15-day encounter-and-submission window to expire.
• Trying to reuse the old encounter after a request expires.
• Using the sample PDF as a submission form.
• Asking the evaluator to reveal or inflate scores.
• Assuming six encounters mean acceptance before all electronic statuses and ECFMG review are complete.
• Trying to reuse prior-season evaluations.
• Waiting until February 15 without Match-processing buffer.

Master Pathway 6 checklist

• MyIntealth confirms Pathway 6 is my required route.
• My Application for ECFMG Certification is Accepted or Pending Credential Verification.
• I reviewed the current Pathway 6 page and exclusion notice.
• I identified three to six evaluators plus a reserve.
• Every evaluator has a current full unrestricted license in the encounter jurisdiction.
• Every evaluator has held full unrestricted licensure for at least five years.
• No evaluator is a prohibited relative or receives prohibited compensation.
• I obtained permission to share each evaluator's licensed name and exact email.
• My institution and local law permit me to interview and physically examine patients.
• Every planned setting is a formal outpatient clinic.
• Every encounter will be primary-care/general-practice, not subspecialized.
• Every patient will be a real registered outpatient and not my relative.
• The patient or guardian will give permission.
• I submitted the Pathway 6 application before January 31, 2027.
• I send one request per encounter, including two requests when one physician evaluates twice.
• I confirm accepted status before each encounter.
• I complete the encounter and electronic submission within 15 days of acceptance.
• I perform an interview, appropriate physical, and under-five-minute presentation.
• I do not ask for or receive the confidential evaluation.
• I monitor each dashboard slot to completed.
• All six evaluations will arrive well before February 15, 2027.
• I meet OET Medicine and all separate ECFMG examination and credential requirements.
• I retain no unnecessary patient-identifying information.
• I recheck official rules because procedures can change.

Bottom line

The Pathway 6 Mini-CEX is a controlled sequence, not six signatures: correct eligibility, qualified unpaid evaluator, lawful general outpatient setting, real consenting patient, accepted electronic request, directly observed interview and physical, concise clinical presentation, independent four-domain assessment, and timely portal submission.

Prepare clinical skills before the formal encounters, manage each request around its two 15-day clocks, and create redundancy in evaluators and scheduling. Never trade compliance for speed.

This guide reflects official 2027 Pathways information available July 17, 2026. ECFMG can update requirements, exclusions, portals, and deadlines. The live ECFMG Pathway 6 page and the status in your record control whenever they differ from a summary.