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PURPOSE OF THE USMLE
In order to practice
clinical medicine in an unsupervised setting (i.e.,outside postgraduate
training programs), all physicians (domestic and international grads
alike) must be licensed by the medical licensing board of the state
where they plan to practice. Each medical licensing authority sets
its own rules and regulations and requires passing an examination
that demonstrates qualification for licensure.
The USMLE consists of
three steps designed to assess a physician’s ability to apply
knowledge, concepts, and principles, and to demonstrate fundamental
patient-centered skills that are important in health and disease
and that constitute the basis of safe and effective patient care.
Each of the three Steps
complements the others; no Step can stand alone in the assessment
of readiness for medical licensure. Because individual medical licensing
authorities make decisions regarding use of USMLE results, you
should contact the jurisdiction where you intend to apply for licensure
to obtain complete information. Also, the FSMB can provide general information
on medical licensure.
USMLE Step 1
The USMLE Step 1 is the first in the series of three USMLE exams that
candidates must pass in order to qualify for medical licensure in the
United States. It is a one-day computer exam taken by most medical students
at the end of their second year of medical school. It is also taken by
thousands of international medical graduates (IMGs) who wish to practice
medicine in the United States.
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Unlike previous USMLE exams in which candidates all took the same test
on the same dates, the computer versions are administered by appointment
on a year-round basis.
The Step 1 emphasizes basic science principles, specifically in anatomy,
behavioral science, biochemistry, microbiology, pathology, pharmacology,
and physiology. Interdisciplinary areas such as genetics, immunology,
and nutrition are also tested.
The Step 1 exam contains 350 questions and spans 8 hours of testing (including
an hour of break time). It is administered as 7 one-hour "blocks" of
50 questions each. You will be able to skip back and forth among test
questions, but only within a particular block. Once you leave a block
(or time expires for that block), you will not be able to return to the
questions of that block.
Step 1 questions are NOT grouped by subject within a block. For example,
you won't find a section devoted to biochemistry. This random ordering
of items presents you with a unique challenge. You must switch from thinking
about one subject, such as pathology, to another, such as behavioral
science.
In total, you will have 45-60 minutes of "break" time depending
on whether you choose to complete the 15 minute tutorial at the start.
You can "add" to your break time by finishing a block early.
Please note, however, that finishing blocks early does not add to your
total "test time" which remains constant at 7 hours. That means
that you can't add time to one block by finishing another block ahead
of time. You should only take breaks BETWEEN blocks; leaving the testing
area DURING a block will be noted as a testing irregularity.
Question Formats
The only question format
currently on the USMLE Step 1 is one best answer (matching questions
as well as negatively phrased questions were eliminated a few years
ago). Some of the Step 1 items test your fund of knowledge directly;
however, the majority require application of basic science principles
to clinically-relevant situations. You will also be asked to identify
microscopic and gross specimens, interpret graphic or tabular information,
and solve simple clinical problems.
In an effort to make the Step 1 exam more medically relevant, the USMLE
items often assess basic medical science concepts in a clinical context.
While some points are asked in a fairly traditional, straightforward
manner, you will also be presented with many clinical vignettes. This
style typically involves fairly long lead-in scenarios followed by relatively
brief response options.
USMLE Step 2
CK
Step 2 assesses whether
you can apply medical knowledge, skills, and understanding of clinical
science essential for the provision of patient care under supervision
and includes emphasis on health promotion and disease prevention.
Step 2 ensures that due attention is devoted to principles of clinical
sciences and basic patient-centered skills that provide the foundation
for the safe and competent practice of medicine.
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The
Step 2 CK exam contains 370 questions and spans 9 hours of testing
(including an hour of break time). It is administered as eight, 1-hour "blocks" of
46 questions each. You will be able to skip back and forth between
test questions, but only within a particular block. Once you leave
a block
(or time expires for that block), you will not be able to return to
the questions of that block.
Step 2 CK questions are
NOT grouped by subject within a block. For example, you won't find
a section devoted to pediatrics. This random ordering of items presents
you with a unique challenge. You must switch from thinking about
one subject, such as surgery, to another, such as obstetrics.
In total, you will have
45-60 minutes of "break" time depending on whether you
choose to complete the 15- minute tutorial at the start. You can "add" to
your break time by finishing a block early. Please note, however,
that finishing blocks early does not add to your total "test
time," which remains constant at 8 hours. That means that
you can't add time to one block by finishing another block ahead
of time.
You should take breaks only BETWEEN blocks; leaving the testing
area DURING a block will be noted as a testing irregularity.
Question Formats
There are two multiple-choice formats used on Step 2 CK:
1. Single best answer
2. Single answer matching
For both formats, there are 3 to 26 answer choices (for the one best
answer format, there are typically 5). Most items describe a patient
and ask you to identify the underlying mechanism of the disease, propose
a diagnosis, order diagnostic studies, or initiate treatment. Questions
that incorporate graphic, tabular, and pictorial material are also included.
STEP 2 CLINICAL SKILLS (CS)
Step 2 CS assesses whether
an examinee can demonstrate the fundamental clinical
skills essential for safe and effective patient care under supervision.
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There are three subcomponents of Step 2 CS:
1. Integrated Clinical
Encounter (ICE):
. Data gathering . patient
information collected by history taking and physical
examination.
. Documentation . completion of a patient note summarizing the findings
of the patient encounter, diagnostic impression, and initial patient
work-up
2. Communication and Interpersonal Skills (CIS):
. Questioning skills
(e.g., use of open-ended questions, transitional statements, not
interrupting the patient)
. Information-sharing skills (e.g., avoidance of jargon, responsiveness
to patient questions or concerns, provision of counseling when appropriate)
. Professional manner and rapport (e.g., concern for patient’s
comfort and modesty, examinee’s attention to personal hygiene,
expression of interest in the impact of the illness)
3. Spoken English Proficiency (SEP):
. Clarity of spoken English
communication within the context of the doctor-patient encounter
(e.g., pronunciation, word choice, and minimizing the need to repeat
questions or statements).
USMLE Step 3
The USMLE* Step 3 is the third in the series of three USMLE exams that
candidates must pass in order to qualify for medical licensure in the
United States. It is a 2-day computerized examination with approximately
500 multiple-choice items administered over the first day and a half
of testing. These items deal with clinical situations typically encountered
by a generalist physician. The exam concludes with a half-day consisting
of approximately 9 open-ended computer-based case simulations (CCS).
More...
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%).
Multiple Choice Sections
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.
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.
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