United States Medical Licensing Examination

The United States Medical Licensing Examination

(USMLE) is a multi-part professional exam 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 of America; see below for requirements
of physicians with a D.O. degree.[1]

fore a physician with an M.D. degree is eligible to apply for an unrestricted license to practice medicine in the
United States. U.S. osteopathic medical school graduates are permitted to take the USMLE for medical licensure, which they can also obtain by passing the multipart Comprehensive Osteopathic Medical Licensing Examination (COMLEX) professional exam. Students who
have graduated from medical schools outside the US and
Canada must pass all three steps of the USMLE to be licensed to practice in the US, regardless of the title of their
degree. Overall pass rates for USMLE Step 1 test takers
in 2013-2014 are: 95% for U.S. M.D. medical school
graduates (97% in rst-time takers), 94% for U.S. D.O.
osteopathic medical school graduates (94% in rst-time
takers), and 72% for international medical school graduates (79% for rst-time takers).[3] Overall USMLE Step
2 CK test taker pass rates in 2013-2014 are: 97% for
U.S. M.D. medical school graduates (98% in rst-time
takers) and 96% for U.S. D.O. medical school graduates (96% in rst-time takers).[4] Overall USMLE Step
2 CS test taker pass rates in 2013-2014 are: 97% for
U.S. M.D. medical school graduates (98% in rst-time
takers) and 89% for U.S. D.O. medical school graduates (89% in rst-time takers), though this gure may be
somewhat misleading since there were 19,757 M.D. rsttime test takers and 63 D.O. rst-time test takers.[5] Overall pass rates for USMLE Step 3 test takers in 2013-2014
are: 96% for U.S. M.D. medical school graduates (97%
in rst-time takers), 92% for U.S. D.O. medical school
graduates (96% in rst-time takers), and 83% for international medical school graduates (87% in rst-time takers). These statistics may be somewhat misleading since
there were 19,086 M.D. rst-time test takers for Step 3
and 23 D.O. rst-time test takers. (In these statistics,
U.S. M.D. medical school graduates includes graduates
of Canadian M.D. programs.)[6]

Purpose

The USMLE assesses a physicians ability to apply knowledge, concepts, and principles, and to determine fundamental patient-centered skills that are important in health
and disease and that constitute the basis of safe and
eective patient care.[2] Examination committees composed of medical educators and clinicians from across the
United States and its territories prepare the examination
materials each year.

Overview

Students and graduates of U.S. or Canadian medical

school programs accredited by either the Liaison Committee on Medical Education (LCME) or Committee
on Accreditation of Canadian Medical Schools, leading to the Doctor of Medicine (M.D.) degree, or by the
American Osteopathic Association (AOA), leading to the
Doctor of Osteopathic Medicine (D.O.) degree, register
for Step 1 and Step 2 of the USMLE with the NBME. Students and graduates of medical schools outside the United
States or Canada register for Step 1 and Step 2 with the
Educational Commission for Foreign Medical Graduates
(ECFMG). Graduates of medical schools in and outside
the United States and Canada register for Step 3 with the
FSMB or with a medical licensing authority in the United
States. Each of the three steps of the USMLE examination complements the other; no step stands alone in
the assessment of readiness for medical licensure. The
USMLE program recommends that for Step 3 eligibility, licensure authorities require the completion, or near
completion, of at least one postgraduate training year in
a program of graduate medical education accredited by
the Accreditation Council on Graduate Medical Education (ACGME) or the American Osteopathic Association
(AOA).

Further information: Comparison of MD and DO in the

United States

3 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.
As of 2007, it covers the following subjects, in both systemic (general and individual anatomical characteristics)
All three steps of the USMLE exam must be passed be- and procedural (functional, therapeutic, environmental,
1

4 STEP 2

and abnormality) themes:

Pathology,
Pharmacology,

reason the Step 1 is unanimously viewed as the most arduous and paramount examination a medical student will
ever sit during his or her entire career. It has substantial
bearing on the specialties and location a residency applicant is competitive for.

Physiology,
Microbiology,
Biochemistry,

4 Step 2

Anatomy,

USMLE Step 2 is designed to assess whether medical

school students or graduates can apply medical knowl Behavioral sciences,
edge, skills and understanding of clinical science essen Interdisciplinary topics, such as nutrition, genetics, tial for provision of patient care under supervision. US
medical students typically take Step 2 during the fourth
and aging.[7]
year of medical school. Step 2 is further divided into two
US medical students take Step 1 at the end of the Basic separate exams.
Sciences portion of the curriculum, usually after the second year of medical school. It is an eight-hour computerbased exam consisting of 322 multiple-choice questions 4.1 Step 2-CK
(MCQs) divided into seven blocks each consisting of 46
questions. As of summer 2008, some questions include USMLE Step 2 CK is designed to assess clinical knowlaudio and video. Each block must be nished within an edge through a traditional, multiple-choice examination.
hour. The remaining hour is break time. An optional It is a 9-hour exam consisting of 8 blocks of approxitutorial about how to use the computer program of the mately 44 questions each. One hour is given for each
exam is oered at the beginning of the exam and takes block of questions. The subjects included in this exam
15 minutes. This time is deducted from the hour of allot- are clinical sciences like Medicine, Surgery, Pediatrics,
ted break time. A quality assurance survey is presented Psychiatry and Obstetrics & Gynecology.
at the end, provided some of the original eight hours is
left over.
Scores are reported as both a three-digit score and twodigit score. However as of July 1, 2011 only the 3-digit
score is reported on USMLE transcripts.[8] The two-digit
score is not a percentile, as many test-takers have been
known to erroneously report, but is instead an obsolete
scale still used internally by some state medical licensing
authorities. On January 1, 2014, the passing score was
raised from 188 to 192.[9] The mean and standard deviation for rst-time examinees from US and Canadian
medical schools, as of July 2014, are 228 and 21, respectively, with most scores falling between 140 and 260
(worldwide, 260, rather than 270, is +2SD); this is up
from 224 and 22, respectively, from December 2012.[10]

4.2 Step 2-CS

The Step 1 score is frequently used in medical residency

applications as a measure of a candidates likelihood to
succeed in that particular residency (and on that specialtys 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.[11] Average USMLE Step 1 scores for various
residencies are available in Charting Outcomes in the
Match. Averages for graduates of U.S. medical schools
who matched into residency range from 213 for a Family
Medicine to 249 for Plastic Surgery.[12]

Philadelphia

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 ndings,
initial dierential diagnosis list and a list of initial tests.
Administration of the Step 2-CS began in 2004. The examination is only oered in ve cities across the country:

Chicago
Atlanta
Houston
Los Angeles

If the student passes the exam, he or she may not repeat Before 2004, a similar exam, the Clinical Skills Assessit to achieve a higher score, and any failed attempt is per- ment (CSA) was used to assess the clinical skills of formanently recorded. This one-time deal situation is the eign medical graduates.

Step 3

Main article: USMLE Step 3

USMLE Step 3 is the nal exam in the USMLE series
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 rst 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. Starting from 2014 USMLE Step 3 will be divided
into two separate parts.[13]

7 Performance
Grade point average in undergraduate science courses
and performance on the MCAT, particularly the biological sciences and physical sciences sections, are strong predictors of performance on the USMLE step 1 and step 2
exams, though it is unclear whether the verbal reasoning
portion of the MCAT has any predictive value.[14] The
selectivity of undergraduate institution is also a predictor
of step 1 and step 2 performance, even when controlling
for undergraduate GPA and MCAT score.[14]

8 Similar exams
The Comprehensive Osteopathic Medical Licensing Examination (COMLEX-USA) is required for
osteopathic physicians in the United States

Step 3 is a 16-hour examination divided over two

days. Each day of testing must be completed within
8.1
eight hours.
The rst day of testing includes 256 multiplechoice items divided into 6 blocks, each consisting of 42-43 items. Examinees must complete each block within sixty minutes.
The second day of testing includes 198
multiple-choice items, divided into 6 blocks of
33 items. Examinees are required to complete
each block within forty-ve minutes. Approximately 3 hours are allowed for these multiplechoice item blocks. Also on the second day are
13 Clinical Case Simulations, where the examinees are required to 'manage' patients in realtime case simulations. Examinees enter orders
for medications and/or investigations into the
simulation software, and the condition of the
patient changes. Cases are of 10 or 20 minutes.
Approximately forty-ve minutes to one hour is
available for break time on each of the two days of
testing.

Format

The USMLE rst started out as a paper examination, converting to a computer based multiple choice examination.
The test can be taken at Prometric test centers worldwide. However, the Step 2 CS and the Step 3 can only
be taken in the USA. The software used to administer
the test, the NBME FREDtm , was upgraded in 2008 to
a new version, FREDtm V2. The implementation of this
changeover continues.

In other countries

Medical Council of Canada Qualifying Examination, in Canada

Professional and Linguistic Assessment Board test
(similar exam used in United Kingdom)
Australian Medical Council (AMC) in Australia.
Medical Council of India (MCI-FMGE conducted
by National Board of Examinations)
Examen Nacional de Aspirantes a Residencias Medicas (ENARM) in Mexico
Saudi Licensing Examination (SLE) in Saudi Arabia
rztliche Prfungen, overseen by the IMPP, in Germany

9 References
[1] United States Court of Appeals for the Third Circuit.
1605859. John Doe v. National Board of Medical Examiners, appellant, D.C. Civ. No. 99-cv-04532. AltLaw
[2] 2010 Bulletin of Information: USMLE. A publication of
the FSMB and the NBME. 2009.
[3] 2013 Performance Data. Step 1 Administrations. Federation of Medical State Boards. 2014. Retrieved 26 February 2015.
[4] 2013 Performance Data. Step 2 CK Administrations.
Federation of Medical State Boards. 2014. Retrieved 26
February 2015.
[5] 2013 Performance Data. Step 2 CS Administrations.
Federation of Medical State Boards. 2014. Retrieved 26
February 2015.

10

[6] 2013 Performance Data. United States Medical Licensing Examination. 2014. Retrieved 26 February 2015.
[7] USMLE web site, 2007 bulletin
[8] USMLE.org.
[9] USMLE.org.
[10] usmle.org
[11] http://www.nrmp.org/data/programresultsbyspecialty.
pdf
[12] http://www.nrmp.org/wp-content/uploads/2014/09/
Charting-Outcomes-2014-Final.pdf
[13] http://medicalopedia.org/2648/
usmle-new-changes-2014-step-3-going-to-be-divided-into-two-parts/
[14] Kleshinski, James; Sadik A. Khuder; Joseph I. Shapiro;
Jerey P. Gold (7 November 2007). Impact of preadmission variables on USMLE step 1 and step 2 performance (PDF). Advances in Health Science Education
(Springer) 14: 6978. doi:10.1007/s10459-007-9087-x.
Retrieved August 22, 2010.

10

External links

USMLE ocial website

For International medical graduates
USMLE Forum

EXTERNAL LINKS

11
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