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). Medical doctors with an M.D. degree are required to pass this examination before being permitted to practice medicine in the United States of America.

The USMLE assesses a physician's 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 effective patient care. Examination committees composed of medical educators and clinicians from across the United States and its territories prepare the examination materials each year.

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 M.D. (Doctor of Medicine) degree, or by the American Osteopathic Association (AOA), leading to the D.O. (Doctor of Osteopathic Medicine) 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).

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. U.S. osteopathic medical school graduates are permitted to take the USMLE for medical licensure, which they can also obtain by passing the multi-part 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 first time USMLE Step 1 test takers are: 92% for U.S. M.D. medical school graduates, 81% for U.S. D.O. osteopathic medical school graduates, and 73% for international medical school graduates. Overall pass rates for first time USMLE Step 3 test takers are: 95% for U.S. M.D. medical school graduates, 95% for U.S. D.O. medical school graduates, and 78% for international medical school graduates. (In these statistics, "U.S. M.D. medical school graduates" includes graduates of Canadian M.D. programs.)

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) and procedural (functional, therapeutic, environmental, and abnormality) themes:


 * Anatomy,
 * Physiology,
 * Biochemistry,
 * Pharmacology,
 * Pathology,
 * Microbiology,
 * Behavioral sciences,


 * 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 322 multiple-choice questions (MCQs) divided into seven blocks each consisting of 46 questions. As of summer 2008, some questions 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. A quality assurance survey is presented at the end, provided some of the original eight hours is left over.

The scores are reported with a three digit score and a two digit score. As of January 1, 2010, the passing score has been raised to 188 from a previous score of 185. The average score is approximately 221 and the standard deviation is 23. If the student passes the exam, he or she may not repeat the exam to achieve a higher score.

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 such as Radiology, Ophthalmology, Plastic Surgery, Orthopedic Surgery and Dermatology usually only accept applicants with high 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 among the most important of several 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 available in Chart 6 on page 9 of "Charting Outcomes in the Match" available at http://www.aamc.org/programs/cim/chartingoutcomes.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 44 questions each. One hour is given for each block of questions. The subjects included in this exam are clinical sciences like 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. Administration of the Step 2-CS began in 2004. The examination is only offered in five cities across the country:


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

Before 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 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 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 16 hour examination divided over two-days. Each day of testing must be completed within eight hours. The first day of testing includes 336 multiple-choice items divided into 7 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 4 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.

Exam Format

 * The USMLE first 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.

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. 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.

Similar exams

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

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.
 * Examen Nacional de Aspirantes a Residencias Medicas (ENARM) in Mexico
 * Saudi Licensing Examination (SLE) in Saudi Arabia