Passing “the Boards," or Step 1 of the United States Medical Licensing Examination (USMLE) is demanding enough, but this series of exams continues with two additional steps. Still, once Step 1 is behind you, many medical students report that Step 2 CK feels like a more manageable hurdle.

_Follow this link for a general overview of the USMLE test series._

Overview

Step 2 of the (USMLE) is the second portion of the three-step exam series that all prospective doctors who want to practice medicine in the United States must pass. This portion is divided into two tests — Step 2 Clinical Knowledge (CK) and Step 2 Clinical Skills (CS). Step 2 CK assesses medical students’ ability to apply clinical science that is essential to patient care in a setting of supervised practice.

Eligibility

Medical students are eligible to take Step 2 CK if they are officially enrolled in or graduates of:

• A U.S. or Canadian allopathic medical school (one that awards MD degrees) accredited by the Liaison Committee on Medical Education (LCME)

• A U.S. or Canadian osteopathic medical school (one that awards DO degrees) accredited by the American Osteopathic Association (AOA)

• A medical school outside of the U.S. or Canada that is listed in the International Medical Education Directory (IMED) and that meets Educational Commission for Foreign Medical Graduates (ECFMG) criteria

Registering

Students and graduates who have attended allopathic or osteopathic medical school in the U.S. or Canada can register for Step 2 CK on the National Board of Medical Examiners (NBME) website; non-U.S./Canadian medical school students or graduates must register on the ECFMG website.

As of 2015, Step 2 CK costs $590. Additional fees may apply for exams taken at international centers or for date and location changes.

Scheduling

When you register for this portion of the USMLE, you must select a three-month block in which to take the exam. Once NBME/ECFMG processes your application (which can take as long as four weeks), the organization will send you a scheduling permit with instructions in how to make an appointment at a Prometric test center. (Prometric also has multiple international locations.)

Students may schedule their test dates up to six months in advance. Scheduling requests are accommodated on a first-come, first-served basis, so it’s important to choose a date as soon as you are sent your scheduling permit. USMLE peak seasons are May through July and November through December. In addition, test centers are closed on local holidays, and there are no exams offered during the first 14 days of January.

# Determining Which Year to Take USMLE Step 2 CK

Since Step 2 CK assesses a medical student’s ability to apply clinical science concepts to medical practice, most students ask to take the exam during their clinical years. Until very recently, the majority of U.S. medical schools covered the basic sciences for the first two years and then sent students to clinical rotations in hospitals for the final two years. Today, many medical schools are changing their curricula to move the clinical education component earlier and have students take basic science courses in conjunction with their clinical experiences. For example, students may study cardiac biochemistry, physiology, and pathophysiology while doing a rotation in a hospital’s cardiac unit.

This shift has permitted medical students greater flexibility in the timing of their Step 2 CK exam. Many students want residency admissions committees to see these scores, and consequently, they often take the test before submitting residency applications in September of their final year of medical school. (Keep in mind that scores may take as long as eight weeks to come back.)

Structure

Step 2 CK is a computer-based, one-day examination that lasts about nine hours. There are approximately 350 multiple-choice questions divided into eight blocks of 60 minutes each. The exact number of questions in each block varies and is displayed at the beginning of each block. Every block is allotted 60 minutes, regardless of the number of questions it has. Once you complete a block, you cannot return to review questions. You will have one 45-minute break, whose duration you can increase by skipping the optional 15-minute tutorial or by finishing a block early.

Content

According to the USMLE website, Step 2 CK focuses on the application of clinical science knowledge “essential for the provision of patient care under supervision and includes emphasis on health promotion and disease prevention."

The test is evaluates knowledge in two distinct areas — physician task (clinical practice) and disease category.

# Physician tasks include:

10–15%

• Medical Knowledge/Scientific Concepts

40–50%

• Patient Care: Diagnosis
  • History/Physical Examination
  • Laboratory/Diagnostic Studies
  • Diagnosis
  • Prognosis/Outcome

30–35%

• Patient Care: Management Health Maintenance/Disease Prevention
  • Pharmacotherapy
  • Clinical Interventions
  • Mixed Management
  • Surveillance for Disease Recurrence

3–7%

• Communication
• Professionalism
• Systems-Based Practice/Patient Safety
• Practice-Based Learning

# Disease categories include:

1–3%

• General Principles of Foundational Science (typically related to normal development)

85–95%

• Immune System
• Blood and Lymphoreticular Systems
• Behavioral Health
• Nervous System and Special Senses
• Skin and Subcutaneous Tissue
• Musculoskeletal System
• Cardiovascular System
• Respiratory System
• Gastrointestinal System
• Renal and Urinary Systems
• Pregnancy, Childbirth, and the Puerperium
• Female Reproductive System and Breast
• Male Reproductive System
• Endocrine System
• Multisystem Processes and Disorders

1–5%

• Biostatistics and Epidemiology/Population Health
• Interpretation of the Medical Literature

In contrast to Step 1, which students have long complained assesses detailed basic science topics with no direct clinical application, many medical students view the Step 2 CK focus on the application of clinical knowledge as more relevant to their ultimate medical practice.

Scoring

Step 2 CK scores range from 1–300, with a national average in the 230s and a standard deviation of about 20. In 2015, the minimum passing score is 209, though most residency programs in the U.S. require a score of 220 or above. Candidates pursuing competitive specialties, moreover, need to earn scores well above the 240s.

The Step 2 CK score report includes the following information:

• Tester

  • Pass vs. Fail
  • Three-digit score
  • Graphical performance profiles for each testing category

• Test

  • Overall passing score in a three-digit number
  • Mean score
  • Standard deviation

Scores for Step 2 CK are usually available three to four weeks after testing, but USMLE recommends allowing up to eight weeks in case there are testing irregularities. If you're planning to include your scores in your residency application, then it's advisable to take this test by July before your final year of medical school.

The USMLE is a demanding, lengthy series of exams, but many students believe Step 2 CK has the virtue of being more closely linked to actual medical practice than the Boards. With thoughtful planning and preparation, medical students are indeed able to clear this hurdle on their path to a rewarding career as a doctor.

_Looking for help with taking the Boards? Check out Dr. Miller's overview of the USMLE Step 1 and her tips and tricks for passing it. You can also find additional guidance and expert answers about preparing for the USMLE on Noodle._

See my upcoming article Tips and Preparation for Step 2 CK.