MEDICAL

I. THE USMLE EXAMINATION

THE PURPOSE OF THE EXAM

The USMLE serves as a series of licensing/certification examinations for the practice of medicine in the United States. It is designed to demonstrate how well you understand and apply concepts integral to the basic and clinical sciences. All physicians must pass all three steps of the USMLE before they can practice medicine in the United States.

Items on the exam are not just questions to be answered, but problems to be solved. Good USMLE questions test the student's capacity to think about important medical knowledge and apply it in specific situations.

You can do well on this exam, but doing your best requires both forethought and preparation. This preparation must be on several levels. First, you must be familiar with the types of questions you will face, as well as the overall structure of the exam itself. Second, you must organize your study time efficiently to get the most out of it. Third, you must know how to use the content tested, not just recognize it. You must be able to apply it in hypothetical situations. Fourth, you must physically and mentally prepare yourself for the task at hand. In short, you must know the exam, master the material tested, and be prepared to handle yourself during this often stressful time.

II. THE SEQUENCE OF THE USMLE EXAMS

The USMLE examinations are designed to test Basic Science (Step 1), Clinical Science (Step 2), and Patient Management (Step 3) knowledge in an integrative, cross-discipline manner. The USMLE is designed to be a sequential series of examinations, with each Step testing a progressively higher level of knowledge and understanding.

A. Step 1 is intended to certify that candidates have the basic science knowledge to allow them to benefit from contact with patients in a supervised setting. Fundamentals are tested in USMLE Step 1 via knowledge-based questions that test factual information. Mechanisms are tested via clinical tasks in which students are asked to apply Basic Science concepts in the context of a patient encounter. Test-takers must decide what is the core basic-science issue tested on each presented question.

1. STEP 1 STRUCTURE

As of May 1999, the USMLE Step 1 exam is a computer-based exam (CBT). The exam is no longer being offered in its previous paper-and-pencil format. This means, among other things, that not all students will take the exam on the same day, or even in the same month.

The content of the CBT is similar to previous exams, but the way of testing you is different. In this CBT format, the Step 1 exam consists of multiple-choice questions administered over a total examination time of 8 hours. Of these 8 hours, one hour is available for a tutorial, lunch, and bathroom breaks, leaving 7 hours for answering questions. Note that in contrast to the previous two-day paper exam, the CBT exam now spans only one day. The time per question is about the same as recent paper-and-pencil versions of the test. All students taking the exam will have the same number of questions to answer and the same amount of time in which to answer them. Students will face about 350 questions in all, divided into 7 blocks of 50 questions each. One hour is allowed for each block of questions. If you finish a block early, the remaining minutes go towards breaks only and cannot be saved up for use in subsequent question blocks.

Although all students will be tested in the same content areas, all students will not see the same questions. Many different versions of each exam are available, and the specific exam faced by a given student is determined by random assignment. Different forms of the test will be used at different locations, on different days, and even within the same day. The NBME says that they have hundreds of different versions of the test. The question pool from which each exam will be drawn is the same for everyone, whether they sit for it in New York, California, or Singapore. Students from International Medical Schools face the same exam pool as students from US (LCME accredited) Medical Schools.

The score required to pass the Step 1 exam will remain essentially the same as for the previous paper-and-pencil versions. This means that students will still need to get approximately 60% of the questions correct to pass.

The CBT format allows for greater flexibility in offering pictures, photographs, and other visual material as a part of test questions. Pictures may be in either black and white or color. Types of photographs used include gross pathology, histopathology, blood smears, dermatopathology, and imaging such as CT anatomy, cerebral angiograms, and plain film fractures.

The Step 1 Exam is not currently "adaptive". In its current form, the questions faced by each student are fixed and do not change in response to a student's performance. That is, each student is assigned a single set of 350 questions to complete.

You'll begin your preparation by taking a confidential diagnostic test to identify the areas you need to focus on the most. Our computer analysis provides customized feedback, including a personal study plan to help you manage your time. You'll have access to Kaplan's library for USMLE-like practice items with the comprehensive explanations of right and wrong answer choices.

2. STEP 1 CONTENT

The Step 1 exam features questions drawn from the content areas of seven core subjects: Anatomy, Behavioral Sciences, Biochemistry, Microbiology/immunology, Pathology, Pharmacology, and Physiology. On most exams, a bit more emphasis is placed on second year courses, which are typically Pathology, Pathophysiology (not a specifically designated board subject), Pharmacology, and, often, Microbiology. This does not mean you should neglect the other disciplines in your studying. Doing well on this exam means mastering each of these subjects in turn.

Questions for the USMLE exam are written by selected medical school faculty from across the United States. It is considered an honor to be nominated to write questions for the exam. Each of the seven core basic science areas has its own committee that reviews submitted questions and evaluates their suitability for inclusion on the test. As a general rule, inclusion on the exam requires a consensus from each of the members of the subject committee. In addition to the seven subject committees, the USMLE has formed a number of Task Forces to focus on constructing questions that reach across traditional subject boundaries. Inclusion of integrative questions that draw from a number of separate disciplines has been a priority for the USMLE over the past several years.

B. Step 2 allows candidates to demonstrate that they have sufficient clinical expertise to provide patient care under supervision. Questions are always in the context of a patient encounter. Students must demonstrate a grasp of important mechanisms as they apply to these encounters. With a clinical application focus, the correct answers require detailed diagnostic, hence basic patient management knowledge. Test-takers must recognize the core primary-care issue addressed on each question.

1. USMLE Step 2 Structure

USMLE Step 2 is a nine-hour, computerized examination in the clinical sciences. The exam consists of approximately 400 questions, divided into eight "blocks" of one hour each. Each of the eight blocks contains approximately 50 questions from the full range of topics covered on the exam. You will be able to skip back and forth among test questions, but only within a block of questions. Once the hour is up, you will be unable to return to that block of questions. When you start the testing session, your session clock will begin counting down from nine hours. When the nine hours are up, the test will shut off completely.

Within your nine-hour session time, you will have to complete eight, one-hour sections. The additional hour can be used to view the tutorial (up to 15 minutes) and to take breaks including lunch. If you skip the tutorial (which you should because you can review it on the USMLE's demo disk) you will have a full hour of break time.

henever you begin a new block, the section clock will count down from 60 minutes (the session clock will continue to count down from the original nine hours). When you complete a section (block), you'll get information about how many sections you have left, as well as your remaining session time. If you complete a section early, you can add those minutes to your rest time. You can never add minutes to your test time.

We encourage you to see the exam not as one long exam of 400 questions, but instead as a series of eight, small, 50-question quizzes. Learn to deal with the exam 50 questions at a time.

2. USMLE STEP 2 CONTENT

Subjects covered on the USMLE Step 2 include internal medicine, obstetrics and gynecology, pediatrics, preventive medicine and public health, psychiatry, emergency medicine, dermatology, neurology, geriatrics, and surgery. The USMLE Step 2 content outline is broken down two ways: by normal conditions and disease categories referenced by organ system, and by physician tasks. The tasks include promoting health and health maintenance, understanding mechanisms of disease, establishing a diagnosis, and applying principles of management.

The questions on the exam are presented in a random, interdisciplinary sequence; there are no "content-specific" sections. This makes the exam quite challenging, as you are required to possess mental agility to jump back and forth among many topic areas. Test questions focus on topics that are relevant to the practice of medicine. All the questions are presented in multiple-choice format.

The question stems on the Step 2 exam tend to be considerably longer than those on Step 1, almost always including a case history and laboratory data. Interpretation of physical signs and symptoms, clinical and personal histories, tables, imaging studies, and the results of other diagnostic studies are frequently required.

C. Step 3 is designed to test a physician's capacity for the unsupervised practice of medicine by testing his or her ability to problem solve in a variety of clinical situations. Specific patient management knowledge is tested by means of clinical scenarios. Candidates are asked to display appropriate clinical judgment by ordering and interpreting tests, arriving at correct diagnoses, specifying proper treatment regimens, and arranging for necessary follow-up. The key challenge is selecting the most appropriate management for patients with multiple medical problems and social constraints.

1. Format

Computer-based Case Simulations (CCS)

Computer-based case simulations (CCS) are a new testing format on the Step 3 exam and comprise the last 3 hours and 45 minutes of testing. Multiple patient cases are used to assess your ability to evaluate history and physical examination information, order diagnostic tests, select initial therapies, and manage the patient as he/she responds to your clinical interventions. The CCS format assesses your clinical judgment in a more "realistic" way than multiple-choice questions do.

The Step 3 patient simulations are delivered using NBME's PrimumTM Software, which allows simulation of physician/patient encounters in a variety of settings. You manage the case without prompting, typing in a variety of diagnostic and treatment options. The software recognizes thousands of possible entries that you can type into the order sheet and is programmed with results for any intervention or test you choose.

As you move the case clock forward, you receive the results of the tests you ordered and the patient's status changes based on the underlying medical problem and in response to the specific management decisions made. Acute cases may need to be managed in a short period of case time, whereas patients with chronic problems will require management over months of simulated time.

Question Formats

There are three question formats used in the multiple-choice sections of Step 3:

Single Best Answer

These items, which are the most commonly used, typically have four or five answer choices. You will be asked to select the one best response. Some negatively phrased items are used. In these items, the negative word or phrase is capitalized for emphasis (e.g., LEAST, NOT, EXCEPT).

Multiple Item Sets

In multiple item sets there is a vignette followed by several questions. The items are designed to be answered independently of one another and focus on different aspects of the case presentation.

Case Clusters

In case clusters, as in multiple item sets, several questions all relate to an initial vignette. However, in case clusters, new information is added as the case unfolds over time from item to item. It is imperative that you answer the questions in the order given since the case changes from one item to the next; you need to answer each item based only on the information revealed about the case up to that point.

2. Content

The Step 3 exam focuses primarily on patient management (45-55% of the questions). Other "physician tasks" tested include history and physical (8-12%), lab and diagnostic studies (8-12%), diagnosis (8-12%), prognosis (8-12%), and pathophysiology (8-12%). In addition to "physician tasks," each question also falls into one of three clinical encounter frames: initial workup (20-30%), continued care (55-65%), and emergency care (10-20%).

The multiple-choice part of the test is divided into blocks of 25-50 items. You will have 30-60 minutes to complete each block. Detailed clinical situations are provided for each item and are frequently accompanied by pictorial material and laboratory data. Unlike Steps 1 and 2, in which questions in a block do not relate to each other in any way, the questions in a Step 3 block all belong to the same clinical setting. Items in each block represent one of four settings in which you could encounter a patient:

1. Satellite health center
2. Physician's office
3. Hospital
4. Emergency department

At the beginning of each block, you are told which clinical setting you are dealing with and are given information about what sort of resources are available in that setting.