United States Medical Licensing Examination (USMLE) is a medical licensing examination developed and conducted by Federation of State Medical Boards (FSMB) and National Board of Medical Examiners (NBME). It is a three step exam for medical licensing. It assesses knowledge and skills expected in a physician.
USMLE consists of three steps- Step 1, Step 2 (Clinical knowledge – CK and Clinical Skills – CS), and Step 3. Step 1, Step 2 CK, and Step 2 CS can be taken in any sequence. However, these steps must have completed before going for step 3.
The eligibility criteria for taking Step 1, Step 2 CK and Step 2 CS involve satisfaction of one of the following conditions-
- The applicant is enrolled in a medical program of MD degree, which is accredited by Liaison Committee on Medical Education (LCME).
- The applicant is enrolled in a medical degree of DO degree, which is accredited by American Osteopathic Association (AOA).
- The applicant is enrolled in a medical program, of a medical school outside United States and Canada which satisfies the criteria set by ECFMG.
The eligibility criteria for taking Step 3 involves satisfaction of below mentioned conditions-
- The applicant must have completed a MD degree or its equivalent, or DO degree.
- The applicant must have passed Step 1 and Step 2 examinations. If applicant has graduated from a medical school outside United States and Canada, he/she must have completed “Fifth Pathway” program or received certification from ECFMG. This involves passing both Step 2 CS and Step 2 CK. ECFMG grants certification provided medical school of the candidate and year of his/her passing are catalogued in International Medical Education Directory (IMED) of Foundation for Advancement of International Medical Education and Research (FAIMER).
- The applicant must be satisfying requirements established by respective medical licensing authority.
The three steps of USMLE are explained below:
Step 1: – The content areas covered in the Step 1 examination include anatomy, biochemistry, physiology, pathology, behavioral sciences, microbiology, pathology and other interdisciplinary subjects. According to system organs, this test is breakdown into General principles (25% to 35% of exam), and particular organ systems including hematopoietic/ lymphoreticular, nervous system, endocrine, cardiovascular, immune, skin/ connective tissue, reproductive, gastrointestinal, musculoskeletal, renal/urinary, and respiratory systems (65% to 75% of test). According to processes, Step 1 exam is breakdown into normal structure and function (20% to 30% of exam), Principles of therapeutics (15% to 25% of exam), Abnormal processes (40% to 50% of exam), and Psychosocial, occupational, cultural, and environmental considerations (10% to 20% of exam). This examination assesses a candidate’s ability to apply knowledge of science in solving clinical problems, perform interpretation of clinical data, and identify pathologic and normal specimens.
Step 2 Clinical Knowledge: – The content areas covered in Step 2 Clinical Knowledge examination include pediatrics, internal medicine, psychiatry, obstetrics and gynecology, surgery, preventive medicine and other areas pertaining to care under supervision. This test can be breakdown by two dimensions- disease categories and physician task. According to disease category, exam covers normal growth and development, general principles of care, and various types of disorders such as immunologic disorders, cardiovascular disorders, endocrine and metabolic disorders, diseases of blood and blood forming organs, diseases of respiratory system, mental disorders, nutritional and digestive disorders, diseases of nervous system and special senses, gynecologic disorders, diseases of musculoskeletal system and connective tissues, renal, urinary and male reproductive systems, disorders of skin and subcutaneous tissue, and disorders of childbirth, pregnancy, puerperium. According to physician tasks, this test is breakdown into Promoting preventive medicine and health maintenance (15% to 20% of exam), Establishing a diagnosis (25% to 40% of exam), Understanding mechanisms of a disease (20% to 35% of exam), and Applying principles of management (15% to 25% of exam). In each question, a clinical situation is described and examinee has to write a diagnosis, prognosis, medical care plan or identify mechanisms of disease.
Step 2 Clinical Skills- This examination involves demonstration of practical skills of carrying out patient care under supervision. This test is breakdown into three components- integrated clinical encounter, communication and interpersonal skills, and spoken English proficiency. A candidate has to demonstrate clinical skills over standard patients i.e. people who are trained to depict a real patient. The integrated clinical encounter (ICE) component involves data gathering and documentation. Candidate has to gather patient’s information by doing physical examination and taking his/her history. The patient’s information has to be documented in the form of a patient note by summarizing diagnostic impression, findings and developments. The communication and interpersonal skills component assesses ability to interact with a patient professionally. It assesses skills in questioning patient, sharing information and building trust. Spoken English proficiency is third component of this exam. A candidate is tested if he/she can communicate fluently and clearly in English while interacting with a patient or not.
Step 3- In this examination, there are two types of questions- multiple choice and premium computer-based case simulations (CCS). This test can be breakdown by two dimensions- clinical encounter frame and physician tasks. According to clinical encounter frame, exam is breakdown into- initial care (20% to 30% of exam), continued care (50% to 60% of exam), and emergency care (15% to 25% of exam). So, Step 3 exam assesses knowledge and skills required for dealing with a range of patients including who visit for first time in non-emergency situations, who visit physician frequently and patients brought in emergency situations. According to physician tasks, test is breakdown into- Taking history and doing physical examination (8% to 12% of exam), Formulating most likely diagnosis (8% to 12% of exam), Applying scientific concepts and mechanisms of diseases (8% to 12% of exam), Using laboratory and diagnostic studies (8% to 12% of exam), Evaluating severity of patient’s problem (8% to 12% of exam), and Patient management like clinical intervention, health maintenance, legal and ethical issues, and clinical therapeutics (45% to 55% of exam). In computer based simulation questions, examinee’s decision making skills are tested. He/she is provided with a simulated patient and has to request diagnostic data and carry out medication. Each step taken by examinee is recorded and scored by a computer.
Step 1, Step 2 CK and Step 3 exams consist of multiple choice questions. There are 322 multiple choice questions in Step 1 examination, which are delivered in seven 60 minutes blocks. The time taken for administering Step 1 examination is an eight hours session. There are 346 multiple choice questions in Step 2 CK examination, which are delivered into eight 60 minutes block. Step 2 CK exam is administered in a nine hours session. There are 12 patient cases presented to an examinee in Step 2 CS exam. The examinee gets 15 minutes for patient encounter and 10 minutes for writing patient note. Step 2 CS is administered in an eight hours session. Step 3 exam consists of 480 multiple choice questions and 9 to 12 simulation cases. These MCQs are delivered in blocks of 35 to 50 questions, which are to be attempted in 45 to 60 minutes time. The simulation cases are delivered in blocks of one or two cases which are to be attempted in 22 to 25 minutes time.
The results of Step 1, Step 2 CK and Step 3 examinations are reported as scaled scores either in three digits or two digits format. The three digit scores lie in range from 140 to 260. Some states require two digits scores where passing score is set to be 75. The result of the Step 2 CS examination is a “Pass” or “Fail” without any numerical score. The examinee must begin all blocks in a test session otherwise it is reported as “incomplete examination”. Similarly, in Step 2 CS, a case begun must be completed otherwise it is reported as “incomplete” in transcript. The current scaled passing scores of Step 1, Step 2 CK and Step 3 exams are 188, 189, and 190 respectively.
The exam reports of Step 1, Step 2 CK and Step 3 are reported within three to four weeks from the test date. These exam reports contain scaled scores, Pass/Fail information, and performance profiles. The result of Step 2 CS is reported as per schedule.
Step 1 and Step 2 CK examinations are available at Prometric centers around the world and Step 3 examination is offered at Prometric centers located only in United States and its territories. The candidates of medical schools accredited by AOA or LCME have to follow instructions given on National Board of Medical Examiners (NBME) website for applying and scheduling Step 1 and Step 2 examinations. The candidates of medical schools outside United States and Canada have to follow instructions given on Educational Commission for Foreign Medical Graduates (ECFMG) website for applying and scheduling Step 1 and Step 2 examinations. The candidates require following instructions given at Federation of State Medical Boards (FSMB) website for applying and scheduling Step 3 examination. A candidate requires contacting respective registration entity (NBME, ECFMG, or FSMB) and submitting application materials and fees. The eligible candidates receive scheduling permit containing instructions for scheduling and taking an examination.
Step 1 and Step 2 CK examinations can be scheduled within three months eligibility period in which exam date must fall six months in advance from application. Step 2 CS can be scheduled anytime in a year within 12 months eligibility period.
A candidate is given maximum six attempts to clear an examination. All the three step examinations must be passed within seven years period.
USMLE fees structure is as follow-
Step 1 examination: – $780 + international testing charges if applicable
Step 2 CK examination: – $780 + international testing charges if applicable
Step 2 CS examination: – $1,355
Step 3 examination: – $745 or higher (depending upon state medical board)