By: Dr. Rabia

The United States Medical Licensing Examination (USMLE) is a three-step examination for medical licensure in the United States and is sponsored by the Federation of State Medical Boards (FSMB) and the National Board of Medical Examiners (NBME). Physicians with an M.D. degree are required to pass this examination before being permitted to practice medicine in the United States.

The USMLE assesses a physician’s ability to apply knowledge, concepts, and principles, and to determine fundamental patient-centred skills that are important in health and disease and that constitute the basis of safe and effective patient care. Examination committees composed of medical educators and clinicians from across the United States and its territories create the examination materials each year. At least two committees critically appraise each test item or case, revising or discarding any materials that are in doubt. All three steps of the USMLE exam must be passed before a physician with an M.D. degree is eligible to apply for an unrestricted license to practice medicine in the United States.

STEP 1:

USMLE Step 1 assesses whether medical school students or graduates understand and can apply important concepts of the basic sciences to the practice of medicine. 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. Step1 is constructed according to an integrated content outline that organizes basic science material along two dimensions: system and process. It includes the following subjects:

1. Anatomy
2. Behavioural sciences
3. Biochemistry
4. Microbiology
5. Pathology
6. Pharmacology
7. Physiology

Interdisciplinary topics, such as nutrition, genetics, and aging.

PATTERN:

Step 1 is a one-day examination. It is divided into seven 60-minute blocks and administered in one 8-hour testing session. The number of questions per block on a given examination form will vary but will not exceed 40. The total number of items on the overall examination form will not exceed 280.

US medical students take Step 1 at the end of the Basic Sciences portion of the curriculum, usually after the second year of medical school. 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), and it has been cited by residency program directors as their most important criterion in selecting graduating medical students for their residency program. Average USMLE Step 1 scores for various residencies are available in Charting Outcomes in the Match.

If the student passes the exam, he or she may not repeat it to achieve a higher score, and any failed attempt is permanently recorded. This “one-time deal” situation is the reason the Step 1 is unanimously viewed as the most arduous and paramount examination a medical student will ever sit during his or her career. It has substantial bearing on the specialties and location a residency applicant is competitive for.

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 Clinical Knowledge assesses whether medical school students or graduates 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-centred skills that provide the foundation for the safe and competent practice of medicine.

Step 2 CK is a one-day examination. It is divided into eight 60-minute blocks, administered in one 9-hour testing session. Test item formats may vary within each block. It is constructed according to an integrated content outline that organizes clinical science material along two dimensions: physician task and disease category. It includes the following subjects: internal medicine, obstetrics and gynaecology, paediatrics, preventive medicine, psychiatry, surgery, other areas relevant to provision of care under supervision.

STEP 2 CS:

USMLE Step 2 Clinical Skills assesses the ability of medical school students or graduates to 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 the principles of clinical sciences and basic patient- centred skills that provide the foundation for the safe and effective practice of medicine. The exam contains the following subjects:

Integrated Clinical Encounter (ICE)
Communication and Interpersonal Skills (CIS)
Spoken English Proficiency (SEP)

Step 2 CS uses standardized patients to test medical students and graduates on their ability to gather information from patients, perform physical examinations, and communicate their findings to patients and colleagues. The examination is offered in five U.S. cities: Philadelphia, Chicago, Atlanta, Houston, Los Angeles.

Administration of the Step 2-CS began in 2004. Prior to 2004, a similar exam, the Clinical Skills Assessment (CSA) was used to assess the clinical skills of foreign medical graduates.

STEP 3:

USMLE Step 3 is the final exam in the USMLE sequence and 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. Graduates of US medical schools typically take this exam at the end of the first year of residency. Examinee are tested on the following subjects: central nervous system, eye/ear/nose/mouth/throat, respiratory system, circulatory system, digestive system, behavioural/emotional disorders, musculoskeletal system, skin/subcutaneous tissue, endocrine/nutrition/metabolic disorders, kidneys/urinary tract, reproductive system, pregnancy/childbirth, neonate/childhood illnesses, blood and blood-forming organs, infectious/parasitic diseases, injuries/wound/toxic effects/burns, and health maintenance issues.

Step 3 is a two-day examination. The first day of testing includes 233 multiple-choice items divided into 6 blocks of 38-40 items; 60 minutes are allotted for completion of each block of test items. Items with an associated pharmaceutical advertisement or scientific abstract are included in each of these multiple-choice blocks. There are approximately 7 hours in the test session on the first day.

There are approximately 9 hours in the test session on the second day. This day of testing includes 180 multiple-choice items, divided into 6 blocks of 30 items; 45 minutes are allotted for completion of each block of test items. This is followed by 13 case simulations, each of which is allotted a maximum of 10 or 20 minutes of real time.