USMLE

The United States Medical Licensing Examination (USMLE) is an exam conducted jointly by the Federation of State Medical Boards of the United States and the National Board of Medical Examiners.

The USMLE assesses a physician's ability to apply knowledge, concepts, and principles, and to demonstrate fundamental patient-centered skills, that are important in health and disease and that constitute the basis of safe and effective patient care. Each of the three Steps of the USMLE complements the others; no Step can stand alone in the assessment of readiness for medical licensure. Because individual medical licensing authorities make decisions regarding use of USMLE results, physicians seeking licensure should contact the jurisdiction where they intend to apply for licensure to obtain complete information. Also, the FSMB can provide general information on medical licensure.

Step1

The USMLE Step 1 (more commonly just Step 1) is the first part of the United States Medical Licensure Examination. Step 1 assesses whether you understand and can apply important concepts of the sciences basic to the practice of medicine, with special emphasis on principles and mechanisms underlying health, disease, and modes of therapy. Step 1 ensures mastery of not only the sciences that provide a foundation for the safe and competent practice of medicine in the present, but also the scientific principles required for maintenance of competence through lifelong learning. Step 1 is constructed according to an integrated content outline that organizes basic science material along two dimensions: system and process.

Step 1 is designed to test the knowledge learned during the basic science years of medical school. This usually includes anatomy, biochemistry, histology, physiology, neuroscience psychiatry, genetics, pathology, microbiology, molecular biology, Pharmacology, immunology and statistics. Epidemiology, medical ethics and questions on empathy are also emphasised. The exams are dynamically generated for each individual test taker, so while the general proportion of questions from each subject is relatively the same for each person, some test takers report that certain subjects are either emphasized or deemphasized on their particular exam.

Exam Structure
Traditionally, the exam was an eight-hour single-day computer-based test composed of seven 50-question sets (350 multiple-choice questions in total). However, as of May 9, 2008 the number of questions has been reduced to 48 questions per set with a total of 336 questions for the day. The time provided for each section has not changed. Each section is one hour long, allotting a minute and fifteen seconds for each question. The test taker is permitted 45 minutes in total for the whole day for the purpose of breaks that can only be taken between sections. There is a 15 minute tutorial at the beginning of the exam, which the test-taker can choose to skip, and have the time added to the break time. If the taker finishes any section before the alloted 1 hour time limit, the remainder of the time is added to break time. The test is administered at Prometric testing sites around the world.As of 2008, the USMLE has begun using a small number of audiovisual questions on Step 1. These questions generally have interactive animations and may have audio components, such as heart sounds, which must be evaluated by the test taker. These questions are currently considered experimental, and the USMLE is delaying score reporting during Summer 2008 to evaluate the results of the new questions.

Scoring
The Step 1 score report is given as a three-digit and two-digit score. The 3-digit score is calculated using statistical procedures that ensure that scores from different years are on a common scale and have the same meaning. The 2-digit score is derived from the 3-digit score; it is not a percentile. It is used in score reporting to meet requirements of some medical licensing authorities that the passing score be reported as 75. Those who take the exam on or after January 1, 2007, will need a score of 185 to pass in the exam. The overall yearly average is approximately 215 with a standard deviation of 20. In recent years, the mean score for U.S. and Canadian first-time test takers was 218 and the standard deviation was 23. Many residency programs have cutoffs for Step 1 scores below which applicants are unlikely to be interviewed. You can estimate your percentile score with the USMLE Score Calculator.

Importance of Step 1 in Residency Matching
Performance on this test is one of the selection criteria used in the NRMP match program for residencies. A favorable score on this test indicates that the medical student has grasped the core scientific knowledge taught during the 'basic sciences' years of medical education. It is also impotrant in the sense  that it is the only standardized measure of all applicants across all nationalities. Students in U.S. medical schools take this test at the end of their second year of medical school and it is usually required for progression into the third year of medical school. The test is standardized and it allows medical students to be directly compared with each other on a national basis although the creators of the USMLE wish that scores not be used for this purpose.

Click here for Step 1 content and more information

Step 2

Step 2 assesses whether you can apply medical knowledge, skills, and understanding of clinical science essential for the provision of patient care under supervision and includes emphasis on health promotion and disease prevention. Step 2 ensures that due attention is devoted to principles of clinical sciences and basic patient-centered skills that provide the foundation for the safe and competent practice of medicine.

Clinical Knowledge (CK)

The USMLE-Step 2-CK ("Clinical Knowledge") is the multiple-choice portion of the Step 2 of the USMLE, that assesses clinical knowledge through a traditional, multiple-choice examination. In contrast to the USMLE Step 1, the focus is much more on clinical application of medical knowledge. Step 2 CK is constructed according to an integrated content outline that organizes clinical science material along two dimensions: physician task and disease category.

Exam Structure
The exam is a nine-hour single-day computer-based test composed of eight 46-question sets (368 multiple-choice questions in total). Each section is one hour long. The test taker is permitted 45 minutes, in total for the whole day, for the purpose of breaks that can only be taken between sections. There is a 15 minute tutorial at the beginning of the exam, which the test-taker can choose to skip, and have the time added to the break time. If the taker finishes any section before the alloted 1 hour time limit, the remainder of the time is added to break time. The test is administered at the Prometric testing sites around the world. Scoring is reported in 2 digit and 3 digit scores. Student is required to get 75 and 185 scores to pass the exam in 2 digit and 3 digit scores respectively.

Topics covered include:

• infectious and parasitic diseases
  
• neoplasms
  
• immunologic disorders
  
• diseases of the blood and blood-forming organs
  
• mental disorders
  
• diseases of the nervous system and special senses
  
• cardiovascular disorders
  
• diseases of the respiratory system
  
• nutritional and digestive disorders
  
• gynecologic disorders
  
• renal, urinary, and male reproductive systems
  
• disorders of pregnancy, childbirth, and the puerperium
  
• disorders of the skin and subcutaneous tissues
  
• diseases of the musculoskeletal system and connective tissue
  
• endocrine and metabolic disorders
  
• congenital anomalies
  
• conditions originating in the perinatal period
  
• symptoms, signs, and ill-defined conditions
  
• injury and poisoning

Click here for Step 2 CK content and general information

Clinical Skills (CS)
Step 2 CS uses standardized patients, i.e., people trained to portray real patients. The cases cover common and important situations that a physician is likely to encounter in clinics, doctors’ offices, emergency departments, and hospital settings in the United States. It is comparable to the COMLEX-USA Level 2-PE exam, taken by osteopathic medical students/graduates who seek licensure as physicians in the U.S.

Exam Structure
The USMLE Step 2 CS exam consists of a series of patient encounters in which the examinees must see the simulated patient (SPs), take a history, do a physical examination, determine differential diagnoses, and then write a patient note based on their determinations. The topics covered are common outpatient or Emergency Room visits which are encountered in the fields of internal medicine, surgery, psychiatry, pediatrics, and Obstetrics and Gynaecology. Examinees are expected to investigate the simulated patient's chief complaint, as well as obtain a thorough assessment of their past medical history, medications, allergies, social history (including alcohol, tobacco, drug use, sexual practices, etc.), and family history.

The USMLE Step 2 CS exam consists of a series of patient encounters in which the examinees must see the simulated patient (SPs), take a history, do a physical examination, determine differential diagnoses, and then write a patient note based on their determinations. The topics covered are common outpatient or Emergency Room visits which are encountered in the fields of internal medicine, surgery, psychiatry, pediatrics, and Obstetrics and Gynaecology. Examinees are expected to investigate the simulated patient's chief complaint, as well as obtain a thorough assessment of their past medical history, medications, allergies, social history (including alcohol, tobacco, drug use, sexual practices, etc.), and family history.

Examinees are allowed 15 minutes to complete each encounter and 10 minutes for the patient note for a single patient encounter. The patient note is slightly different than a standard SOAP_note. For the exam note, the examinees will document the pertinent facts relating to the history of present illness as well as elements of the past medical history, medication history, allergies, social history, family history, and physical exam. The examinees will then state up to 5 differential diagnoses relating to the simulated patient's symptoms, and up to 5 tests or procedures to investigate the simulated patient's complaints; the examinees will not recommend any specific treatments in the note in contrast to a true clinic SOAP note (ie, IV fluids, antibiotics, or other medications). Over the course of an 8-hour exam day, the examinees complete 12 such encounters.

USMLE Step 2 CS replaced the former ECFMG Clinical Skills Assessment (CSA) effective June 14, 2004. The last administration of the ECFMG Clinical Skills Assessment (CSA) took place on April 16, 2004.

Grading
The test is graded on a straight pass/fail basis, without any numerical score associated with it (as opposed to the other parts of the USMLE series). In order to pass, one must achieve a grade of "pass" in each of the three sub-components of the exam.

Integrated Clinical Encounter (ICE) - This component includes the ability of the examinees to collect pertinent clinical information from the SP, and to write an appropriate patient note with differential after the clinical encounter. The former part is graded by the simulated patient, and the latter by a practicing physician.
Communication and Interpersonal Skills (CIS) - This component includes evaluating the examinees' question asking skills (asking open ended questions, avoiding repetition and medical jargon), information sharing skills (acknowledging patient concerns, providing counseling and information about what will happen in the future), and professionalism / rapport (asking about feelings and concerns, showing consideration for patient comfort, proper hygiene during examinations, providing empathy and respect for the simulated patient).
Spoken English Proficiency (SEP) - This component includes clarity of spoken English communication in the context of pronunciation, word choice, and minimizing the need to repeat questions or statements.

Exam centers
USMLE Step 2 CS can be taken only in the USA. Currently there are 5 testing centers called the Clinical Skills Evaluation Center (CSEC) throughout the USA:

Atlanta, Georgia
Chicago, Illinois
Houston, Texas
Los Angeles, California
Philadelphia, Pennsylvania

Click here for Step 2 CS content and general information

Step 3

Step 3 is the final exam in the USMLE series of examinations. It is part of the licensing requirements for M.D.s, D.O.s, and FMGs to practice medicine in the United States. It is considered as the final step in the series of medical licensure examinations. It generally is a pre-requisite of the majority of the state licensing boards.

Step 3 assesses whether you can apply medical knowledge and understanding of biomedical and clinical science essential for the unsupervised practice of medicine, with emphasis on patient management in ambulatory settings. Step 3 provides a final assessment of physicians assuming independent responsibility for delivering general medical care. A principal organizing dimension for Step 3 design is normal conditions and disease categories. Second and third organizing dimensions are the clinical encounter frame and physician tasks. Step 3 content reflects a data-based model of generalist medical practice in the United States.

Click here for Step 3 Content and general information

Click here for USMLE FAQs

Click here for USMLE Information Bulletin

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