The United States Medical Licensing Examination® (USMLE)

The United States Medical Licensing Examination^® (USMLE) is a three-step assessment program that evaluates medical students and physicians intending to practice medicine in the United States. Sponsored by the Federation of State Medical Boards^® (FSMB) and the National Board of Medical Examiners^® (NBME), the USMLE assesses an individual's ability to apply their medical knowledge and demonstrate fundamental patient-centered skills. Passing the USMLE is required for physicians with a Doctor of Medicine (MD) degree for medical licensure, and for international medical graduates (IMGs) for Educational Commission for Foreign Medical Graduates^® (ECFMG) certification, which enables them to enter residency or fellowship programs in the US that are accredited by the Accreditation Council for Graduate Medical Education (ACGME). The USMLE is not required for those with a Doctor of Osteopathic Medicine degree (DO), but over 60% also take at least USMLE Step 1, in addition to their required licensure exam, the Comprehensive Osteopathic Medical Licensing Examination of the United States^®, or COMLEX.

The USMLE is split into three distinct steps in the form of computerized examinations. Step 1 tests the examinee's foundational understanding of the basic sciences, including anatomy, physiology, biochemistry, and pharmacology, all of which are typically integrated with pathology. Step 2 Clinical Knowledge (CK) focuses on the clinical sciences and the application of this knowledge to patient care under supervision. The Step 2 Clinical Skills (CS), which examined an examinee's communication and patient care skills through simulated patient encounters, was discontinued in 2021. Finally, Step 3 assesses the ability to independently understand and apply medical knowledge in an unsupervised clinical setting, with a focus on patient management in outpatient settings.

The article USMLE® Content Outline contains exam-related content for all three USMLE exams (USMLE Step 1, Step 2 CK, and Step 3). In addition to the AMBOSS article in the previous sentence, the original outline can be accessed at: https://www.usmle.org/sites/default/files/2022-01/USMLE_Content_Outline_0.pdf. Each exam's coverage of content varies according to system, discipline, and physician tasks and competencies. The number of questions and total duration are also different for each exam, as described below.

Step 1 is a one-day, 8-hour computer-based examination that consists of: ^[1]

• Up to 280 multiple-choice questions divided into seven 60-minute blocks
• Up to randomized 40 questions in each block (so 90 seconds per question)
• 45 minutes of break time for the examination session that can be allocated during authorized breaks.
• An optional, 15-minute tutorial at the start.
• Time remaining after completing the tutorial or a block is added to the total break time.

The “Step 1 Content Outline and Specifications” website categorizes the exam's relevant content (from the USMLE® Content Outline) into the systems, disciplines, and physician tasks and competencies below (last updated: Dec. 2022). ^[2]

Systems

Disciplines

Physician tasks and competencies

NBME question theory highlights

• The NBME emphasizes the understanding and application of knowledge in a clinical context rather than fact recall.
• Items should reflect “real-life tasks.”
• The NBME writes that a good question should be possible to answer without looking at the options.
• Questions intentionally include unimportant findings and extraneous information, known as “Window dressing,” to reflect more realistic scenarios and assess an examinee's ability to filter important from unimportant information.

Types of questions

• There are only single-item questions (A-type items).
  • Has one best answer (“most likely”), though other options may be partially correct
  • Consists of a vignette, lead-in question, and ≥ 4 lettered options arranged in alphabetical or logical order
    • Most items have 5 answer options.
    • Range of answer option: 4–10, although rarely > 6
  • Can include an image, audio, or video findings
  • Can include graphic or tabular material
• After 1. identifying important findings, and 2. integrating with knowledge, an examinee is usually tasked withing either:
  • Guessing: drug, toxic exposure, diet, mood
  • Predicting: finding (history, physical, lab) or sequela associated with (most likely) diagnosis
  • Identifying: underlying cause or diagnosis, drug, verbal response
• There is a mix of first-order and second-order questions.
  • First-order question: Can be answered directly from the content provided without an intermediate step, e.g., determining a diagnosis based on the clinical findings.
  • Second-order question: Requires reasoning in an intermediate step towards a condition or scenario that enables answering the question, e.g., first determining what condition a patient has to be able to answer a question on how to treat them.
• Questions are based on two scenarios:
  • Clinical vignette (∼ 90%): A patient interaction.
  • Experimental vignettes (∼ 10%): An experiment, study, or lab procedure provides context for testing basic science concepts
• Unlike Step 2 CK or Step 3:
  • No matching or sequential sets
  • No abstract or drug ads
  • No patient charts

Multimedia questions

• Image or illustration: ∼ 4 per block
  • Patient photos, histology, pathology, radiographic studies
  • Labeling of anatomy or illustrations as options: up to 1 per block
• Graphs/charts: ∼ 1 per block
• Examination video: 1–2 questions (e.g., resting tremor of Parkinson disease)
• Interactive media of avatars for auscultation points: 1–2 questions (i.e., recognize heart murmurs/sounds)
• Communication/ethics videos (rare): to emphasize response to patient behavior, intonation, body language

Question stems

• Clinical vignettes include some or all of the following components:
  1. Presentation: Age, gender → physician/site of care → presenting complaint(s) → duration
  2. → History: related history → past medical history → social history → family history → risk factors: smoking, alcohol, recreational drugs → medications
  3. → Physical: appearance → vital signs → examination
  4. → Diagnostic findings: laboratory → histology/pathology → ECG → imaging → other tests → possibly a diagnosis
  5. → Follow-up info: initial treatment, subsequent findings, complications, etc.
  6. → Lead-in: “which of the following” and “most likely”
• The order stays the same (and replicates a clinical case).
• Size of vignettes for Step 1: average ∼ 5 sentences (range: 2–13)

As of January 26, 2022, Step 1 score reporting changed from a numeric score and pass/fail outcome to pass/fail only. Step 1 scores are based on a 3-digit scale that ranges from 1–300. As of Jan. 2023, the current minimum passing score is 196.

Score reports ^[3]

• Score reports for Step 1 are released on a Wednesday, typically 3–4 weeks after the examination date (often 1–2 weeks longer over the winter holidays). For information regarding how to access a score report, visit the USMLE Examination Results and Scoring website (see “Tips & Links” below).
• A passing score report is one page containing:
  • Test result of “Pass”
  • Visual representation of the content weighting on the exam for physician task, system, and discipline
  • No scores or any indication of relative performance (unlike a failing report)
• A failing score report is four pages showing:
  • Test result of “Fail”
  • On failing score reports only: a chart showing an examinee's score in comparison to the minimum passing score and distribution of performance
  • Relative strengths and weaknesses, described via performance in a content area (physician tasks, systems, disciplines) as statistically lower than, same as, or higher than those with a low-pass
  • Visual representation of the content weighting on the exam

Past score statistics ^[4]

It is unlikely that the NBME will release further reports of the means and standard deviations from first-time examinees of Step 1 from US and Canadian medical schools. Past years are included here for reference:

Pass rates ^[5]

The percent passing rate for Step 1 in 2022 was as follows:

Step 2 CK is a one-day, 9-hour computer-based examination that consists of: ^[1]

• Up to 318 multiple-choice questions divided into eight 60-minute blocks
• Up to randomized 40 questions in each block (so 90 seconds per question)
• 45 minutes of break time for the examination session that can be allocated during authorized breaks.
• An optional, 15-minute tutorial at the start.
• Time remaining after completing the tutorial or a block is added to the total break time.

The “Step 2 CK Content Outline and Specifications” website categorizes the exam's relevant content (from the USMLE® Content Outline) into the systems, disciplines, and physician tasks and competencies below (last updated: Dec. 2022). ^[2]

Systems

Disciplines

Physician tasks and competencies

Tasks

• The vast majority of Step 2 CK questions focus on patient care, including diagnostic steps and diagnosis, management and pharmacotherapy, prognosis, and prevention.
  • Although basic science concepts are no longer directly tested, as with Step 1 and Step 3, they are necessary to understand and are often integrated into patient care concepts, such as expected laboratory values, diagnostic findings, pharmacotherapy mechanisms, and underlying causes or outcomes as they relate to pathophysiology.
• Some questions ask about how to react to best practices of patient care, professionalism, systems-based practice, and patient safety.

Single-item questions

• The most frequently used multiple-choice format
• Consists of a vignette, question, and 3–26 lettered options arranged in alphabetical or logical order
• Can include image, audio, or video findings
• Can include graphic or tabular material
• Has one best answer, though other options may be partially correct

Sequential item sets

• Consists of a clinical vignette with 2–3 associated multiple-choice questions with one best answer
• Questions must be answered in sequential order.

Abstract and drug ad formats

• Abstract format (usually 1–2 per exam): Consists of a summary of an experiment or clinical investigation that is typically presented as a medical journal abstract with 2 multiple-choice questions with one best answer
• Drug ad (usually 1 per exam): Consists of an informational pamphlet that might be distributed by a pharmaceutical company with diagrams and summarizing information, typically of a recent clinical trial that investigates the indications and adverse effects of a new drug.
• Questions focus on the interpretation of medical literature and may pertain to biostatistics, epidemiology, diagnostic studies, pharmacotherapy, and/or clinical intervention.

Patient chart format (experimental)

• Since 2021, the NBME has been testing patient chart formats, in which the stem resembles the information that might be provided in a patient note (remember SOAP).
• The breadth of topics and the approach to answering is the same as question items with classic clinical vignettes.

Score reports

• Step 2 CK scores are reported on a 3-digit scale that ranges from 1–300. As of Jan. 2023, the current minimum passing score is 214.
• Score reports for Step 2 CK are released on a Wednesday, typically 3–4 weeks after the examination date (often 1–2 weeks longer over the winter holidays). For information regarding how to access a score report, visit the USMLE website (see “Tips & Links” below).
• A score report is four pages showing:
  • Test result of “Pass” or “Fail”
  • 3-digit score
  • A chart showing an examinee's score in comparison to the minimum passing score and distribution of performance, including the mean and standard deviation.
  • Relative strengths and weaknesses, described via performance in a content area (physician tasks, systems, disciplines) as statistically lower than, same as, or higher than those with a low-pass
  • Visual representation of the content weighting on the exam

Past score statistics ^[4]

The means and standard deviations from first-time examinees of Step 2 CK from US and Canadian medical schools, is as follows:

Pass rates

The percent passing rate for Step 2 CK in 2021–2022 is was follows:

For complete details on registering for the USMLE steps, visit the USMLE website (see “Tips & Links” below).

Step 1 and Step 2 CK registration

Obtain a scheduling permit

US and Canadian program students

• Apply through the National Board of Medical Examiners (NBME) on the NBME Licensing Examination Services (NLES) website.
• The nonrefundable registration fees for Step 1 and Step 2 CK in 2023 are $660 each.
• Registration confers a 3-month eligibility period for the examination date (e.g., November 1, 2022–January 31, 2023, October 1, 2023–December 31, 2023).
  • A one-time extension of the eligibility period costs $70.
  • If the examination is not taken within the eligibility period, the examinee must reapply with a new application and fee.

Non-US and Canadian program students

• Apply through the Educational Commission for Foreign Medical Graduates (ECFMG) on the Interactive Web Applications (IWA) website.
• The nonrefundable, one-time fee to apply for ECFMG certification is $160.
• The nonrefundable registration fees for Step 1 and Step 2 CK are $985 each with an additional international test delivery surcharge of $185 for Step 1 and $210 for Step 2 CK if the examination is taken outside of the US or Canada.
• Registration confers a 3-month eligibility period for the examination date (e.g., November 1, 2022–January 31, 2023, October 1, 2023–December 31, 2023).
  • For specific information on additional fees (e.g., to extend the eligibility period or change the testing region), visit the ECFMG website (see “Tips & Links” below).
  • If the examination is not taken within the eligibility period, the examinee must reapply with a new application and fee.

Scheduling a Step 1 or Step 2 CK examination date

• After receiving the scheduling permit for Step 1 or Step 2 CK, schedule an appointment to take the examination at a Prometric test center up to 6 months in advance.
  • There is no fee for changing the appointment ≥ 46 days before the scheduled examination date within the eligibility period.
  • There is a fee for changing the appointment within 45 days of the scheduled examination date. Fees vary between $35 and $369 and can be found at https://www.usmle.org/reschedule-exam.

Free resources

• Free sets of 119 sample Step 1 questions and 120 sample Step 2 questions (the “free 120”) are available from the USMLE website (see “Tips & Links” below) in both:
  • PDF format
  • Web browser-based practice testing experience that has the same format as the computer-based examination used at Prometric test centers.

Prometric practice sessions

• Examinees can register for a one-time practice session at a Prometric test center in the same testing region as their Step examination.
  • Enables the examinee to become familiar with the Prometric environment.
  • The questions are the same as the free sample questions available online (see “Free resources” above).
  • Lasts a maximum of 3.5 hours, with three 1-hour blocks of ∼ 40 questions each.
• Nonrefundable fees for a practice session:
  • US and Canada: $75
  • International: $155

Online self-assessments: CBSSA and CCSSA

Each step has a correlating self-assessment, each with different versions known as forms.

• As NBME self-assessments are very representative of their correlating exam performance, it is highly recommended to complete at least one form for each exam.
• One strategy is to utilize a self-assessment at the start of the dedicated period to establish a baseline, and then potentially more later on to follow progression.
• The self-assessment results also provide some details of performance for the different content areas (system, discipline, physician task/competency).
• Each form consists of 200 multiple-choice questions divided into four sections of 50 questions per section.
• Examinees can purchase one of two formats:
  • Standard-paced: 1 hour and 15 minutes to complete each section
  • Self-paced: 5 hours to complete each section
• Each self-assessment costs $60 and can be completed online within 90 days after purchase.
• Examinees can log out and resume the self-assessment at any time during the 90-day period.

In contrast to the format of the CBSSAs and CCSSAs, the current format of Steps 1 and 2 CK consists of blocks of up to 40 questions with 1 hour to complete each section.

Examinees can take Step 1 and Step 2 in any order, but US medical schools have certain requirements for when the exams should be completed for their students. Step 3 can only be taken after both Step 1 and Step 2 are completed.

US and Canadian program medical students and graduates

Students can take Step 1 and Step 2 in any order, but medical schools have certain requirements for when the exams should be completed. Step 3 can only be taken after both Step 1 and Step 2 are completed.

• Most students are required to take Step 1 at the end of the 2^nd preclinical year and Step 2 CK after their 1^st clinical year.
• There are, however, some medical schools that accelerate entry into clinical rotations as part of the 2^nd-year curriculum. While some medical schools still require Step 1 before rotations, others require it at the end of their rotations, either before taking Step 2 CK or giving students the choice to take it even after Step 2 CK.
  • Taking Step 1 before clinical rotations may help to prepare them for seeing patients and facilitates better performance on clinical rotations and shelf exams.
  • Taking Step 1 after clinical rotations enables utilizing information learned during clinical rotations, which helps solidify the understanding and retention of tested concepts. It also refreshes overlapping Step 2 CK concepts and objectives, which can be advantageous if taking Step 2 CK shortly after. However, scheduling time to prepare for and take Step 1 in between clinical rotations can be challenging.
• Board-certified physicians must complete Step 3 by the end of residency. US students who have passed both Step 1 and Step 2 CK may take the exam before graduation, but it is typically completed during or at the end of the first year of residency.

Non-US and Canadian program medical students and graduates (IMGs)

• Although students can take Step 1 and Step 2 CK in any order, most choose to first take Step 1. Since many concepts and objectives overlap between the exams, many examinees take Step 1 and then study for and take Step 2 CK in succession. It is generally recommended to wait until after related content has been taught as part of the examinee's curriculum before pursuing to prepare for these exams.
• In order to take Step 3, IMGs must be ECFMG certified, which requires passing Step 1, Step 2 CK, and requirements for clinical and communication skills via an ECFMG Pathway that includes passing an Occupational English Test (OET) or having a valid passing performance on the former Step 2 CS.
  • To help strengthen residency applications, many IMGs choose to take Step 3 even before applying or in parallel with the Match process.
  • Regardless, those who practice medicine in the US will need to take Step 3 by the end of residency; it is typically completed during or at the end of the first year of residency.

Plan ahead! Examination dates can fill up very quickly and score reporting can be delayed.

Before the examination

• Review the USMLE Rules of Conduct available from the USMLE website (see “Tips & Links” below).
• Review the Prometric test center regulations available from the Prometric website (see “Tips & Links” below).
• Prepare a copy of the Scheduling Permit (electronic and/or paper)
• Prepare your valid identification.
  • Examinees must bring a valid, unexpired identification (e.g., passport, driver's license with photograph) that contains their name (which must match the name on the Scheduling Permit), photograph, and signature.
• Arrive at least 30 minutes before the scheduled examination appointment time.
  • Examinees who arrive after the appointment time may not be admitted. If examinees arrive more than 30 minutes after the scheduled examination appointment time, they will not be admitted and will have to reschedule the examination.

What to wear

• Wear comfortable clothes. Examination room temperature and personal comfort vary, so bring a sweater or jacket.
• Light clothing items removed for comfort (e.g., sweaters, scarves) must be hung on the examinee’s chair (not placed on laps or on the workstation desktop).
• Examinees cannot remove articles of clothing (e.g., overshirts, sweaters) while in the examination room.
• Outerwear (e.g., heavy coats), hats, watches, and jewelry items (except for wedding and engagement rings) are not permitted in the examination room.
• Be prepared for the following security procedures:
  • Electronic fingerprinting
  • Scanning with a metal detector wand
  • Raising pants above the ankles and pulling long sleeves above the wrists
  • Emptying and turning pockets inside out
  • Removing eyeglasses and hair accessories (e.g., headbands, clips) for visual inspection

What to bring

• Copy of the Scheduling Permit (electronic and/or paper)
• Valid identification
• Water, lunch, and/or snacks, which examinees can access during authorized breaks
• Optional: soft ear plugs (without wires or cords)

During the examination

• Follow the regulations set by the USMLE Rules of Conduct and Prometric. These regulations include, but are not limited to:
  • Putting all personal belongings (e.g., cell phone, study materials) in the provided locker and only accessing these items during authorized breaks
  • Not bringing any unauthorized items into the examination room
  • Not writing on any surface other than the note board provided by the Prometric test center.
• The examination begins when the examinee enters their Candidate Identification Number (CIN) into the computer.
  • To receive a score, the examinee must either finish the examination or run out of total examination time. If the examinee leaves the examination before finished, an incomplete attempt will be documented, and no score will be generated.

Breaks

• See “Step 1 description” above for information on break time.
• Authorized breaks can be taken at any time between examination blocks.
  • Examinees can remain at their seats or leave the examination room during authorized breaks. If they leave the examination room, they must undergo the same security procedures as when they first entered the examination room.
• Unauthorized breaks (e.g., leaving the room for a personal emergency) are reported to the USMLE.
  • The examination clock will continue to run during unauthorized breaks.
  • Locked items (e.g., cell phones) cannot be accessed during unauthorized breaks.
• If the examinee exceeds the total break time, the excess is deducted from the total examination time.

After the examination

• Feelings vary greatly among individuals, but one thing is common: almost everyone feels mentally exhausted.
• It is also very common to wonder if you did well enough to pass or sometimes even to feel that you will fail.
  • But something to realize is that it is in human nature to spend a great deal of mental energy on the things we are not doing well at.
  • In other words, it is easy to get hung up on the dozen or so questions you did not know the answer to and forget the other couple of hundred that you did know.
• You should feel proud of this major feat you have accomplished, regardless of the results.
• Congratulate yourself on this major milestone, celebrate, and rest up!
• Do not share any content from the examination.

Unfortunately, for varying reasons, not everyone may pass the examination on the first attempt. While this may be very frustrating, potentially embarrassing, and even demotivating, take heart in knowing that you are not alone. Thousands of students have failed these exams but were able to come back, pass them, get into residency programs, and continue their career path.

Restrategizing

It is time to come up with a new game plan.

• Utilize the score report to help analyze the content areas that require more studying.
• If not already in touch with the medical school's learning specialist, reach out to them for their support and guidance.
• If still struggling, consider working with a tutor to help recalibrate.

Common issues involve not utilizing superior study strategies.

• The best learning should be difficult: struggled learning with active recall is far superior to comfortable learning with passive repetition.
• Ensure you are focusing the vast majority of your studying with USMLE-style questions, and during dedicated, preferably randomized and timed to reflect testing conditions and train answering questions quickly enough.
• Any concepts that you did not know from doing questions should be recorded and reviewed with spacing (e.g., in the form of personalized Anki decks).
• The AMBOSS Qbank offers thousands of high-yield USMLE-style questions to serve the needs of all examinees. The Qbank is also unique in that the key info, attending tip, and multimedia overlay can all assist in training valuable test-taking skills while learning the content.

Retaking an examination

• Examinees who have passed a step are not allowed to retake the examination, unless necessary to comply with time limits imposed by a medical licensing authority.
• It cannot be taken more than 3 times within a 12-month period. A fourth can only be taken > 12 months after the first attempt and > 6 months after the most recent attempt.
• Each Step may be attempted up to four times. If not passed by then, the applicant is no longer eligible to apply for the USMLE steps.
• Most state medical boards require all Step examinations to be completed within a specific time frame (usually 7 years).