United States Medical Licensing Examination

The United States Medical Licensing Examination or 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 are required to pass before being permitted to practice medicine in the United States of America. It consists of three steps; all three must be passed before an allopathic medical school (M.D.) graduate is eligible to apply for a license to practice medicine in the United States. U.S. osteopathic medical school graduates are permitted to take the USMLE exam for medical licensure, but they may also get medical licensure in most states by taking the Comprehensive Osteopathic Medical Licensing Examination (COMLEX) instead. International medical school graduates must pass all three steps of the USMLE regardless of whether they have an M.D. or a D.O. degree. Overall pass rates for first time USMLE Step 1 test takers are: 93% for U.S. allopathic medical school (M.D.) graduates, 76% for U.S. osteopathic medical school graduates, and 71% for foreign medical school graduates.

The USMLE steps are:

Step 1
USMLE Step 1 assesses whether medical school students or graduates understand and can apply important concepts of the sciences basic 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 ab/normality) themes:
 * Anatomy,
 * Behavioral sciences,
 * Biochemistry,
 * Microbiology,
 * Pathology,
 * Pharmacology,
 * Physiology,
 * 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 350 multiple-choice questions (MCQs) divided into seven blocks each consisting of 50 questions. Beginning in the summer of 2008, some questions will 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.

The scores are reported with a three digit score and a two digit score. As of January 1, 2007, the passing score has been raised to 185 from a previous score of 182. The average score is approximately 215. If the student passes the exam, he or she may not repeat the exam to achieve a higher score. Theoretically, the maximum score is 300. However, scores above 280 are virtually unheard of.

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 usually accept applications with higher 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 just one of many 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 charted in Figure 4 on page 11 of "Charting Outcomes in the Match" available at http://www.nrmp.org/matchoutcomes.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 46 or 47 questions each. The subjects included in this exam are clinical sciences like Internal 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 offered in five cities across the country:


 * Philadelphia (PA)
 * Chicago (IL)
 * Atlanta (GA)
 * Houston (TX)
 * Los Angeles (CA)

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 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 a two-day examination. Each day of testing must be completed within eight hours. The first day of testing includes 336 multiple-choice items divided into 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 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.

Similar exams

 * The "Comprehensive Osteopathic Medical Licensing Examination" (COMLEX-USA), is required for osteopathic physicians in the United States of America
 * Professional and Linguistic Assessment Board test (similar exam used in United Kingdom)
 * NCLEX-RN and NCLEX-PN (used for nurses in the United States)