The USMLE
What is the USMLE?
The United States Medical Licensing Examination, or USMLE for short, is a three-part licensing examination that is required in order to receive a license to practice medicine within the United States. This exam is designed by the Federation of State Medical Boards and the National Board of Medical Examiners to determine whether or not an individual understands and can apply the knowledge necessary to practice medicine safely and intelligently. The USMLE is actually comprised of three different exams that are referred to as steps, which examine the individual's knowledge of specific topics related to the field of medicine such as basic science, medical knowledge, medical skills, clinical science, and the application of all of these skills and areas of knowledge in the medical field. All three steps of the USMLE include a series of computerized multiple-choice questions, but the format of the exam and the information covered in each multiple-choice section is different for each step of the USMLE. The USMLE Step II also has a clinical skills portion that examines an individual's ability to work with real patients and the USMLE Step III has a computerized patient simulation portion in addition to the multiple-choice section of the exam. In order for an individual to receive a license to practice medicine, the individual must pass all three steps of the USMLE.
USMLE Step I
The USMLE Step I is the first test of the three-part United States Medical Licensing Examination that is required in order to receive a license to practice medicine within the United States. The test is a computerized exam consisting of 350 multiple-choice questions split into seven sections that are primarily related to knowledge of basic science. The exam takes approximately eight hours to complete with one hour being allotted to each section and an hour break. Each section is not separated by topic, but rather contains 50 randomly distributed questions that pertain primarily to information about Anatomy, Biochemistry, Biology, Behavioral Science, Micro-Immunology, Pathology, Pharmacology, and Physiology. These questions include information related specifically to general principles related to the above areas, the cardiovascular system, the central and peripheral nervous systems, the endocrine system, the gastrointestinal system, the hematopoietic and lymphoreticular systems, the musculoskeletal system, the renal system, the reproductive system, the respiratory system, and the integumentary system.
The exam is scored based on the number of correct responses and then scaled so that the individual will receive a three-digit and a two-digit scaled score. Scores for the three-digit scale usually fall between 140 and 260 with 185 set as the minimum score required to pass the exam. The two-digit scale is not actually an exact percentage score, but still ranges from 0 - 100 with 75 representing the minimum score necessary to pass the exam. The current registration fee for the exam is $470, which will be raised to $480 in 2008.
USMLE Step II - Clinical Knowledge Exam
The USMLE Step II Clinical Knowledge Exam is part of the second test of the three-part United States Medical Licensing Examination that is required in order to receive a license to practice medicine within the United States. The USMLE Step II Clinical Knowledge Exam is a computerized examination that consists of 368 multiple-choice questions that cover a variety of different topics related to the medical field. The Step II Clinical Knowledge Exam, also known as the Step II CK, is split into 8 sections that are not separated by topic, but rather are 46 randomly distributed questions related to disease mechanisms, differential diagnosis, emergency medicine, neurology, patient care management principles, preventative medicine, radiology, and surgical subspecialties. These questions include information specifically related to human development, conditions and disorders occurring during pregnancy, childbirth, and the perinatal period, congenital abnormalities, disorders of the puerperium, diseases of the blood and blood-manufacturing organs, diseases of the musculoskeletal system, nervous system, respiratory system, and infectious and parasitic diseases. It also includes information related to cardiovascular disorders, endocrine and metabolic disorders, gynecologic disorders, immunologic disorders, mental disorders, nutritional and digestive disorders, skin disorders, neoplasms, the renal system, the male reproductive system, and questions related to symptoms, signs, and ill-defined conditions.
The Clinical Knowledge Exam is scored based on the number of correct responses and then scaled so that the individual will receive a three-digit score and a two-digit score. Scores for the three-digit scale usually fall between 140 and 260 with 184 set as the minimum score considered as passing for the exam. The two-digit scale is not actually an exact percentage score, but still ranges from 0 - 100 with 75 representing the minimum score necessary to pass the exam. The individual must pass both the Clinical Knowledge Exam and the Clinical Skills Exam in order to pass Step II of the USMLE. The current registration fee for the Step II - CK is $470, which will be raised to $480 in 2008.
USMLE Step II - Clinical Skills Exam
The USMLE Step II Clinical Skills Exam is part of the second test of the three-part United States Medical Licensing Examination that is required in order to receive a license to practice medicine within the United States. The USMLE Step II Clinical Skills Exam is designed to prove whether or not an individual has the skills, knowledge, and general ability necessary to physically examine a variety of patients with common diseases, disorders, and/or other problems. The exam takes approximately eight hours to complete in total, which includes a 30 minute break and a 15 minute break. The exam-taker will spend the entire period of the exam examining patients, diagnosing each patient's condition, communicating with patients, and writing out patient notes. The exact amount of time it will take to examine each patient varies, but the exam-taker is only allowed a maximum of 15 minutes to evaluate each patient and 10 minutes to write out the patient note after the evaluation. For certain parts of the test, the individual taking the exam will not be presented with a patient to examine, but instead will be placed in a room with a phone and will be able to receive a call from a patient. The individual must then gather all of the necessary information from the patient in order to make a diagnosis. During portions of the exam where there is a patient physically present, the exam-taker will be required to conduct a physical examination of the patient in order to make a diagnosis. The exam-taker is expected to carry out the examination in a careful and professional manner and to check the patient for signs of diseases or conditions that might explain the problems the patient is experiencing.
However, the exam-taker is only expected to check for signs that may be relevant to the situation and there are certain types of physical examinations that the exam-taker cannot perform. The physical examinations that are prohibited during the exam are:
Rectal Examinations
Pelvic Examinations
Genitourinary Examinations
Female Breast Examinations
Corneal Reflex Examinations
Throat Cultures and Other Throat Swab Tests
The Clinical Skills Exam is scored simply as a pass/fail grade, but the individual must pass both the Clinical Skills Exam and the Clinical Knowledge Exam in order to pass Step II of the USMLE. The individual will receive the pass/fail grade based on the individual's patient examinations, patient notes, and diagnoses. The current registration fee for the Step II - CS is $1,005, which will be raised to $1,025 in 2008.
USMLE Step II CS - Scoring Format
USMLE Step II CS - Scoring Format: The USMLE Step II CS is scored using a pass/fail system, but the exam is actually split into three separate categories of skills. In order for an individual to pass the exam, the individual must show that they are competent in all three areas by receiving a passing score in each category. The three categories covered on the exam, which are referred to as subcomponents, are Communication and Interpersonal Skills (CIS), Integrated Clinical Encounter (ICE), and Spoken English Proficiency (SEP).
For the communication and interpersonal skills portion of the examination, the individual will be scored based on his or her information-sharing skills, questioning skills, and the individual's ability to work with the patient in a professional and respectful manner. The exam-taker will actually receive his or her score for this area of the exam from the patients that he or she treats during the examination as each patient will be asked to rate the individual's performance in these specific areas. The integrated clinical encounter portion of the exam will assess the individual's ability to gather thorough information about the patient and document that information correctly. This portion of the exam is scored based on a checklist that each patient has to fill out regarding the specific questions and evaluations that the exam-taker performed during the examination and how much information about the patient's condition and treatment the exam-taker shared with the patient. The spoken English proficiency portion of the exam assesses an individual's ability to speak English clearly and the individual's ability to effectively convey important information to the patient. The exam-taker will actually receive his or her score for this area of the exam from the patients that he or she treats during the examination as each patient will be asked to rate the individual based on the number of pronunciation problems the individual has, word-choice errors the individual makes, and how much difficulty the patient has understanding the exam-taker.
USMLE Step III - Day 1
The USMLE Step III is the third and final test of the three-part United States Medical Licensing Examination that is required in order to receive a license to practice medicine within the United States. This test, unlike the other two steps of the USMLE, takes two days to complete as the exam is actually administered in two separate sessions. The first session of the Step III test consists of 336 multiple-choice questions split into seven sections that are related to evaluating patients, applications of clinical skills and clinical science, biostatistics, common diseases and disorders, human development, interpreting medical literature, medical ethics, patient safety, and the management systems, quality control systems, and other systems required in a medical practice to maintain a high level of care. Each section of the test is not separated by topic, but rather contains 48 randomly distributed questions that pertain to the above topics.
The first day of the exam takes approximately eight hours to complete as the exam-taker will have 60 minutes to complete each section of the test, 15 minutes allotted for a tutorial explaining how to use the computerized exam system, and a 45 minute break. The test is scored based on the number of correct responses and then scaled so that the individual will receive a three-digit and a two-digit score. The three-digit and two-digit scores are based on the scores achieved from the first and second day of the exam. Scores for the three-digit scale usually fall between 140 and 260 with 184 set as the minimum score required to pass the exam. The two-digit scale is not actually an exact percentage score, but still ranges from 0 - 100 with 75 representing the minimum score necessary to pass the exam. The current registration fee for the exam, which includes both days, is $655, which will be raised to $670 in 2008.
USMLE Step III - Day 2
The USMLE Step III is the third and final test of the three-part United States Medical Licensing Examination that is required in order to receive a license to practice medicine within the United States. This test, unlike the other two steps of the USMLE, takes two days to complete as the exam is actually administered in two separate sessions. The second session of the Step III test consists of 144 multiple-choice questions split into four sections that are related to evaluating patients, applications of clinical skills and clinical science, biostatistics, common diseases and disorders, human development, interpreting medical literature, medical ethics, patient safety, and the management systems, quality control systems, and other systems required in a medical practice to maintain a high level of care. Each section of the test is not separated by topic, but rather contains 36 randomly distributed questions that pertain to the above topics. The second session of the exam also includes nine computerized patient simulations where the individual will have up to 25 minutes to care for each simulated patient.
The second day of the exam takes a total of approximately eight hours to complete, which includes three hours for the multiple-choice portion of the exam, approximately four hours for the patient simulation portion of the exam, a 45 minute break, and a 15 minute tutorial on how to use the computerized patient simulation software. The test is scored based on the number of correct responses from the multiple-choice section of the exam and the individual's performance on the patient simulations. The total score that the individual achieved for Step III of the USMLE is then scaled so that the individual will receive a three-digit and a two-digit score. The three-digit and two-digit scores are based on the number of correct responses and the patient simulation score from the first and second day of the exam. Scores for the three-digit scale usually fall between 140 and 260 with 184 set as the minimum score considered as passing for the exam. The two digit scale is not actually an exact percentage score, but still ranges from 0 - 100 with 75 representing the minimum score necessary to pass the exam. The current registration fee for the exam, which includes both days, is $655, which will be raised to $670 in 2008.
USMLE Registration - Step I, Step II CS, Step II CK
To register for the USMLE Step I Exam, the USMLE Step II Clinical Skills (CS) Exam, or the USMLE Step II Clinical Knowledge (CK) Exam, the individual applying to take the exam must meet one of the education requirements established by the National Board of Medical Examiners (NBEC) in order to be eligible to take the exam. For these three exams, this means that the individual must be either a current medical student seeking a Doctor of Medicine (MD) degree or a Doctor of Osteopathic Medicine (DO) degree at an accredited school within the United States or Canada or a graduate from an accredited medical school within the United States or Canada with a MD or a DO degree. The individual may also be eligible to take the exam if he or she is a student or graduate of a medical school outside of the United States and Canada that is eligible to apply for certification through the Educational Commission for Foreign Medical Graduates (ECFMG.) If the individual applying for the exam is a foreign student or graduate, the student does not need to be certified by the ECFMG prior to taking any of these exams, but rather only needs to be eligible for certification. In order for a foreign graduate to be eligible for certification by the ECFMG, the individual must have attended a school listed on the International Medical Education Directory (IMED) and either be listed as a current student or a graduate in the directory at the time the individual applies for the USMLE and on the day that the individual takes the exam.
If the individual meets one of these requirements, he or she may apply for a testing permit by contacting the NBEC via their website, fax, e-mail or phone. Once the individual has received a testing permit, the individual can schedule a testing date by contacting Thomson Prometric via their website or by phone. The individual may choose any available testing date within his or her eligibility period to take any of the USMLE Exams. However, there are only a limited number of seats available for each testing date and seats often fill up quickly so applicants may wish to apply for a testing date as soon as possible. The Step I, Step II CS, and Step II CK Exams do not have to be taken in any particular order and the individual may choose to take parts of the Step II Exam before taking the Step I Exam.
USMLE Registration - Step III
To register for the USMLE Step III Exam, the individual applying to take the exam must meet all of the requirements set by the National Board of Medical Examiners (NBEC) and must have completed the Step I Exam, the Step II Clinical Skills Exam, and the Step II Clinical Knowledge Exam prior to applying for the Step III Exam. This means that the individual must have completed these three exams and must have a Doctor of Medicine (MD) degree, a degree that can be substituted for an MD degree, or a Doctor of Osteopathic Medicine (DO) degree prior to applying for the exam. The individual must also meet all of the other requirements for licensure set by the local medical licensing authority for the jurisdiction in which the individual is pursuing licensure in order to take the exam. If the individual applying for the Step III Exam completed a medical program outside of the United States and Canada, the individual must have an ECFMG Certification or a Fifth Pathway Certification from the Educational Commission for Foreign Medical Graduates (ECFMG) prior to applying for the exam.
If the individual meets all of the applicable requirements set by the NBEC, he or she may apply for a testing permit by contacting the NBEC via their website, fax, e-mail, or phone. Once the individual has received a testing permit, the individual can schedule a testing date by contacting Thomson Prometric via their website or by phone. The individual applying for the Step III Exam may choose any available testing date within his or her eligibility period. However, there are only a limited number of seats available for each testing date and seats often fill up quickly so applicants may wish to apply for a testing date as soon as possible.
The USMLE and Licensure within the United States
In order for an individual to receive a license to practice medicine within the United States, the individual must have a Doctor of Medicine (MD) degree, a Doctor of Osteopathic Medicine (DO) degree, or another comparable degree and must have passed Step III of the USMLE. The individual must also have completed at least a one-year internship or a one-year residency program in order to receive licensure. The Step I Exam, the Step II Clinical Skills Exam, and the Step II Clinical Knowledge Exam, are not specifically required in order to obtain licensure, but an individual must pass all of these exams in order to take the Step III Exam. Passing each of these exams is also usually required by each university and medical program in order to receive a MD or DO degree. As a result, the individual must have completed all three steps of the USMLE, achieved a MD, DO, or other similar degree, and have completed at least a one-year internship or a one-year residency program in order to receive a license to practice medicine. Individuals that wish to become accredited as a specialist in a particular field of medicine or eligible to practice as a specialist in a particular medical field by the local medical board will usually be required to fulfill their residency performing the particular specialty they are interested in pursuing. However, there may also be other requirements in addition to these requirements in order for an individual to receive a license to practice medicine and/or to become Board Accredited or Board Eligible as a specialist depending on the regulations set by the local medical licensing authority.
USMLE Registration - Other Fees, Rescheduling Exams, and Retaking Exams
The total registration cost for all three Steps of the USMLE will be approximately $2,655 for individuals planning on taking the exam in 2008. However, these fees are usually raised annually and there are other fees that an individual may have to pay in addition to these fees in order to take a particular exam. Some of the additional fees that an individual may have to pay in order to take one of the USMLE Exams include general rescheduling fees, rescheduling fees associated with missing a test date, and fees associated with other certifications such as the ECFMG Certification if the individual that is applying for the exam is a student or graduate from somewhere other than the United States or Canada. An individual that has already scheduled a testing date with Thomson Prometric can reschedule if there is a problem with the date that the individual has chosen, without penalty, if the individual cancels the test appointment with the testing center no later than 14 days before the testing date. The individual taking the exam may also cancel the test appointment during the 14 days prior to the exam date, but Thomson Prometric will assess a $150 rescheduling fee when the individual attempts to choose another date to take the exam. If the individual attempts to cancel his or her test appointment on the day of the test or simply does not show up for the test, Thomson Prometric will assess a $400 rescheduling fee when the individual attempts to choose another date to take the exam.
If the individual taking the exam fails the exam, the individual has the option to retake the exam an unlimited number of times. However, the individual can only retake the Step II Clinical Skills Exam up to a total of 3 times in a one year period from the date that the individual first takes the exam and can only retake any of the other exams up to a total of 4 times in a one year period from the date of the first exam. There may also be limitations on the number of overall attempts an individual can make for a particular exam set by the local medical licensing authority. In jurisdictions where limits are set, the individual will only receive a license to practice medicine if he or she passes the exam before exceeding the number of attempts allowed by the local medical licensing authority for the jurisdiction that the individual is planning on working in.
Summarization
United States Medical Licensing Examination
The United States Medical Licensing Examination or USMLE is a multi-part professional exam sponsored by the Federation of State Medical Boards (FSMB) and the National Board of Medical Examiners (NBME). Medical doctors are required to pass before being permitted to practice medicine in the United States of America. It consists of three steps; all three must be passed before an allopathic medical school (M.D.) graduate is eligible to apply for a license to practice medicine in the United States. U.S. osteopathic medical school graduates are permitted to take the USMLE exam for medical licensure, but they may also get medical licensure in most states by taking the Comprehensive Osteopathic Medical Licensing Examination (COMLEX) instead. International medical school graduates must pass all three steps of the USMLE regardless of whether they have an M.D. or a D.O. degree. Overall pass rates for first time USMLE Step 1 test takers are: 93% for U.S. allopathic medical school (M.D.) graduates, 76% for U.S. osteopathic medical school graduates, and 71% for foreign medical school graduates .
The USMLE steps are:
• Step 1
USMLE Step 1 assesses whether medical school students or graduates understand and can apply important concepts of the sciences basic to the practice of medicine. As of 2007 it covers the following subjects, in both systemic (general and individual anatomical characteristics) and procedural (functional, therapeutic, environmental, and ab/normality) themes:
Anatomy,
Behavioral sciences,
Biochemistry,
Microbiology,
Pathology,
Pharmacology,
Physiology,
Interdisciplinary topics, such as nutrition, genetics, and aging.
US medical students usually take Step 1 at the end of the second year of medical school. It is an eight-hour computer-based exam consisting of 350 multiple-choice questions (MCQs) divided into seven blocks each consisting of 50 questions. Beginning in the summer of 2008, some questions will include audio and video. Each block must be finished within an hour. The remaining hour is break time. An optional tutorial about how to use the computer program of the exam is offered at the beginning of the exam and takes 15 minutes. This time is deducted from the hour of allotted break time.
The scores are reported with a three digit score and a two digit score. As of January 1, 2007, the passing score has been raised to 185 from a previous score of 182. The average score is approximately 215. If the student passes the exam, he or she may not repeat the exam to achieve a higher score. Theoretically, the maximum score is 300. However, scores above 280 are virtually unheard of.
While not recommended by the creators of the USMLE, the Step 1 score is frequently used in medical residency applications as a measure of a candidate's likelihood to succeed in that particular residency (and on that specialty's board exams). More competitive residency programs usually accept applications with higher Step 1 scores. The Step 1 exam is arguably the hardest and most important examination a medical student will take during his/her career.
The USMLE score is just one of many factors considered by residency programs in selecting applicants. The median USMLE Step 1 scores for graduates of U.S. Medical Schools for various residencies are charted in Figure 4 on page 11 of "Charting Outcomes in the Match" available at http://www.nrmp.org/matchoutcomes.pdf
• Step 2
USMLE Step 2 is designed to assess whether medical school students or graduates can apply medical knowledge, skills and understanding of clinical science essential for provision of patient care under supervision. US medical students typically take Step 2 during the fourth year of medical school. Step 2 is further divided into two separate exams.
• Step 2-CK
USMLE Step 2 CK is designed to assess clinical knowledge through a traditional, multiple-choice examination. It is a 9 hour exam consisting of 8 blocks of 46 or 47 questions each. The subjects included in this exam are clinical sciences like Internal Medicine, Surgery, Pediatrics, Psychiatry and Obstetrics & Gynecology.
• Step 2-CS
USMLE Step 2 CS is designed to assess clinical skills through simulated patient interactions, in which the examinee interacts with standardized patients portrayed by actors. Each examinee faces 12 Standardized Patients (SPs) and has 15 minutes to complete history taking and clinical examination for each patient, and then 10 more minutes to write a patient note describing the findings, initial differential diagnosis list and a list of initial tests.
The examination is offered in five cities across the country:
Philadelphia (PA)
Chicago (IL)
Atlanta (GA)
Houston (TX)
Los Angeles (CA)
• Step 3
USMLE Step 3 is designed to assess whether a medical school graduate can apply medical knowledge and understanding of biomedical and clinical science essential for the unsupervised practice of medicine. Graduates of US medical schools typically take this exam at the end of the first year of residency. Foreign medical graduates can take Step 3 before starting residency in about ten U.S. states. Connecticut is frequently chosen for such purpose because it does not require simultaneous application for licensure, unlike New York.
Step 3 is a two-day examination. Each day of testing must be completed within eight hours. The first day of testing includes 336 multiple-choice items divided into blocks, each consisting of 48 items. Examinees must complete each block within sixty minutes.
The second day of testing includes 144 multiple-choice items, divided into blocks of 36 items. Examinees are required to complete each block within forty-five minutes. Approximately 3 hours are allowed for these multiple-choice item blocks. Also on the second day are nine Clinical Case Simulations, where the examinees are required to 'manage' patients in real-time case simulations. Examinees enter orders for medications and/or investigations into the simulation software, and the condition of the patient changes accordingly. Each case must be managed in a maximum of 25 minutes of actual time.
Approximately forty-five minutes to one hour is available for break time on each of the two days of testing
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