Students who aspire to become doctors in the U.S. know that they will eventually need to take the daunting USMLE. In this series, we lay out the different steps, the concepts they assess, and how each is scored. This first article offers a broad overview of the exam and its component steps.

Importance

The USMLE, formally the United States Medical Licensing Examination, is a famously challenging, three-step exam series that is required for anyone who wants to practice medicine in the United States. The first two steps of the series are typically taken while a student is still in medical school, while the third step takes place after graduation.

The exams are sponsored by two organizations: the Federation of State Medical Boards (FSMB) and the National Board of Medical Examiners (NBME). The USMLE exams, particularly Step 1, are often referred to colloquially as “The Boards."

USMLE scores are used in three major ways:

• Most U.S. medical schools require students to pass Step 1 to graduate — and some also require that they pass Step 2/Clinical Knowledge (CK) and Step 2/Clinical Skills (CS) to receive their degree.

• The scores from the first two steps (Step 1, Step 2 CK, and Step 2 CS) play an important part in assessing medical students for residency training positions in the U.S.

• Passing the last step (Step 3) is required in order to be admitted into U.S.-based specialty boards, such as the American Board of Internal Medicine, but is also required by state medical boards that license doctors to practice in their specialty. (Boards are governing bodies that certify doctors at the state level, as well as in more than 150 specialties.)

Eligibility

Step 1, Step 2 CK, and Step 2 CS may be taken by any student who is enrolled in or has graduated from a:

• U.S. or Canadian allopathic medical school accredited by the Liaison Committee on Medical Education (LCME), leading to an M.D. degree
• U.S. or Canadian osteopathic medical school accredited by the American Osteopathic Association (AOA), leading to a D.O. degree
• Medical schools outside the U.S. or Canada that are listed in the <a href="https://imed.faimer.org/){: target="_blank" } (IMED) and that meet International Medical Education Directory (ECFMG" target="_blank">Educational Commission for Foreign Medical Graduates criteria

Step 3 may be taken by:

• Graduates of an accredited U.S. or Canadian allopathic or osteopathic medical school who have passed Step 1, Step 2 CK, and Step 2 CS
• Graduates of a medical school outside the U.S. or Canada listed in IMED who have obtained certification by the ECFMG and passed Step 1, Step 2 CK, and Step 2 CS

Components

Although the USMLE is referred to as a three-step exam, it requires five days of testing. Moreover, with the introduction of Step 2 CS and a second day of testing for Step 3, preparation may actually need to be even more rigorous than in the past. Still, the consensus among medical professionals is that Step 1 is the hardest of the exams, and each subsequent step gets easier from there.

Below is a brief overview of each USMLE step (each of which I'll be addressing in greater detail in upcoming articles).

# Step 1

• What is tested?: Ability to apply basic science concepts to medical practice
• When is it taken?: Typically taken after the basic science years — that is, after the first two years of medical school
• How long is the exam?: One day, 8 hours
• How many questions are there?: 325 multiple-choice questions
• What is the format?: Computer-based
• Where can you take it?: Prometric test sites internationally

# Step 2 CK (Clinical Knowledge)

• What is tested?: Ability to apply clinical science knowledge in a supervised patient care setting
• When is it taken?: Typically taken during the clinical years — that is, the third and fourth years of medical school
• How long is the exam?: One day, 9 hours
• How many questions are there?: 350 multiple-choice questions
• What is the format?: Computer-based
• Where can you take it?: Prometric test sites internationally

# Step 2 CS (Clinical Skills)

• What is tested?: Clinical skills applied to “ standardized patient" scenarios (that is, actors presenting symptoms or problems a typical doctor may encounter)
• When is it taken?: Typically taken in the fourth year of medical school
• How long is the exam?: One day, 8 hours
• What are the length and format?: 12 patient cases, with 15 minutes for the patient encounter and 10 minutes to record notes for each case
• Where can you take it?: Five test centers (Atlanta, Chicago, Houston, Los Angeles, and Philadelphia)

# Step 3

• What is tested?: Ability to apply clinical science to patients in an unsupervised patient care setting

• When is it taken?: Typically following medical school graduation during residency training

• How long is the exam?: Two days:

  • Day 1 - Foundations in Independent Practice (FIP)
    • Concepts tested: Scientific principles required for effective medical care
    • Duration of Day 1: One day, 7 hours
    • How many questions are there?: 260 multiple-choice questions
  • Day 2 - Advanced Clinical Medicine (ACM)
    • Concepts tested: Applying medical knowledge to patient management and evolving disease processes
    • Duration of Day 2: One day, 9 hours
    • How many questions are there?: 200 multiple-choice questions, 13 computer-based clinical simulations

Scoring

Step 1, Step 2 CK, and Step 3 are each scored on a 1–300 scale. Students can compare scores for each step from year to year — that is, Step 1: 2013 scores to Step 1: 2014 scores — but not between the different steps.

Score reports for these three steps contain the following information:

• If the student passed
• The minimum score needed to pass
• The student’s three-digit score (which is the number most often quoted when students report their USMLE result)
• Performance profile breakdowns for each testing category

Scores for Step 1, Step 2 CK, and Step 3 are generally available four weeks following the exam administration.

Minimum passing scores for 2015 are:

• Step 1: 192
• Step 2 CK: 209
• Step 3: 190

Step 2 CS is only scored as pass/fail, and results for this step can take up to three months to be reported. You can find the Step 2 CS reporting schedule here{: target="_blank" rel="nofollow"}.

Residency admissions committees, specialty boards, and state medical boards often ask for all scores.

Registration

Registration for each USMLE step varies according to the test and medical school location. Step 1, Step 2 CK, and Step 3 (both days) are offered at Prometric test centers on multiple testing days. Students can sign up for each step up to six months in advance of the testing dates.

As mentioned earlier, Step 2 CS is offered in only five cities in the U.S. Once a student has applied for Step 2 CS, NBME/ECFMG assigns a 12-month eligibility period during which a medical student may take the test. Since test sites fill up quickly (usually four or more months in advance), students should schedule the test date before May 31 of the year assigned for this step. Moreover, students do not have their choice of location, but rather will be assigned to a test center in one of these five cities.

# Step 1, Step 2 CK, and Step 2 CS registration:

• U.S. or Canadian M.D. or D.O. students/graduates can register at the NBME website

• Non-U.S. medical school students/graduates can register at the ECFMG website

# Step 3 Registration:

• All graduates of any medical school who have passed Step 1, Step 2 CK, and Step 2 can register for Step 3 at the FSMB website

2015 USMLE Step Fees:

• Step 1: $590
• Step 2 CK: $590
• Step 2 CS: $1250
• Step 3: $815

Note that Prometric charges an additional fee for any appointment change — which could be a date, site, or cancellation — if it is made less than 30 days before the scheduled date of the exam. Moreover, there are also extra charges if a student requests an eligibility period extension or to sit for the exam at an international center.

Miscellaneous

Here are a few odds and ends about the USMLE:

• Step 1, Step 2 CK, and Step 2 CS may be taken in any sequence.
• Step 3 can only be taken once a student has passed Step 1, Step 2 CK, and Step 2 CS.
• Students can take the same exam up to six times.
• No exam may be taken more than three times within a 12-month period.
• Once a student has passed a step, she cannot retake it unless this is required to comply with the time limits of a medical licensing body.
• Students with disabilities may request accommodations, although the USMLE has historically been very strict in approving these. Be sure to plan ahead and learn about the requirements in advance of registering for the exam.