United States Medical Licensing Examination Test (USMLE)

The United States Medical Licensing Examination, which is also known as USMLE is a 3-step exam for getting medical licensure to practice in the USA. The exam is conducted to assess the application skills a physician has after completing their theoretical study. This examination program is owned by the Federation of State Medical Boards and the National Board of Medical Examiners both of which are non-profit organizations representing state boards of the US and its territories.

The examination has its content developed through committees from every part of the US with its committee members including biomedical scientists, educators, and other clinicians. The exam was standardized for the US and its territories to have similar standards for the licensing procedure of allopathic physicians in the country.

This test consists of a 3-step procedure. Each of these three steps in the USMLE exam complements the remaining others, and none of these three steps can stand by themselves individually in assessing readiness, which is needed for getting medical licensure.

Eligibility for Steps 1 and 2 USMLE

The candidate ought to be in 1 of the categories mentioned below while applying for the test.

• Candidate should be a medical student who has officially enrolled in or has graduated from an LCME recognized Medical School in Canada or the US with an MD degree.
• Candidate should be a medical student officially enrolled in or graduated from an American Medical School with a DO degree recognized by COCA.
• Candidate should be officially enrolled in or a graduate of a Medical School in the World Directory of Medical Schools meeting the eligibility requirements of ECFMG.

Eligibility for Step 3 USMLE

Candidates who are applying for the third step of the examination will have to meet the following requirements to complete their application.

• Candidate should get an MD degree (or equivalent to it) or a DO degree.
• Candidate must clear Step 1 and Step 2 CK of USMLE.
• Candidate must obtain the equivalent of an MD degree from a Medical School that comes under the World Directory of Medical Schools which also meets the requirements of ECFMG.
• It is recommended that they also complete at least one year of postgraduate training in an accredited US graduate medical education program due to the practical nature of Step 3.

Fees for USMLE

The fee structure for students/graduates of Medical Schools that are accredited by LCME or AOA in Canada and the US are-

Step	Fee (US/Canada)	Fee (Other Countries)
Step1	$1,000	$1,000 + $195
Step 2 CK	$1,000	$1,000 + $220
Step 3	$925	NA

In addition to the fees specified above, students taking the USMLE outside of the US, its territories, and Canada must pay an international surcharge, as listed in the table above.

Registering for USMLE

Only Prometric centers are authorized to administer Step 1, Step 2 CK, and Step 3. Step 3 of the test is only administered in the United States and its territories, even though the other steps are administered outside of the country as well. The following are the relevant organizations that candidates can register with to take the test:

• For US/Canadian Candidates (including US territories):
  • Step 1 and 2 CK- NBME website
  • Step 3- FSMB Website
• For Candidates outside the US and its territories and Canada: Before applying, medical students and graduates from institutions outside of the US and Canada should see if the World Directory of Medical Schools has their institution listed. They must then adhere to the guidelines provided on the ECFMG website to register for Step 1 and Step 2 CK of the test. To register for Step 3 of the test, they must follow the instructions on the FSMB website.

Candidates need to indicate which eligibility period they would like to test during when they apply for the exam. A scheduling permit with their eligibility period will be issued after their registration is complete. The scheduling permit will be sent to candidates through email. Upon securing the scheduling permit, candidates can go to the Prometric website and book a test date up to six months ahead of time.

Step 1 of USMLE

Step 1 of the examination deals with the different basic and important concepts of the sciences that are required for practicing medicine, but this is focused mainly on the aspects of health, disease, and mode of therapy required for each condition. The competencies that are assessed through the test are Medical Knowledge and Patient Care through Diagnosis. Patient Care through Management, Communication, and Interpersonal Skills, and Practice-based Learning and Improvement.

This section has a maximum of 280 questions in the multiple-choice format which are divided into seven 60-minute blocks. Each of these blocks will have a maximum of 40 questions and a 15-minute optional tutorial. The examination is considered to be one day long since it is conducted at an 8-hour long test session.

The content of the examination will have a flexible nature since the questionnaire is created by experts who focus on emerging domains in the field. This implies that the content of the examination is subject to change with the arrival of newer fields of study. The candidate is supposed to be prepared and up-to-date with their education. The general content of the Step 1 examination of USMLE is-

• General Principles
• Blood and Lymphoreticular/ Immune Systems
• Behavioral Health and Nervous Systems/ Special Senses
• Musculoskeletal, Skin, and Subcutaneous Tissue
• Cardiovascular System
• Respiratory and Renal/ Urinary Systems
• Gastrointestinal System
• Reproductive and Endocrine Systems
• Multisystem Processes and Disorders
• Biostatistics and Epidemiology/ Population Health
• Social Sciences: Communication and Interpersonal Skills

Step 2 of USMLE

This step of the examination deals mainly with the application of medical knowledge to care for patients under supervision. It focuses mainly on health promotion and disease prevention. The exam is titled Clinical Knowledge/ CK. The second part of the exam called CS has been permanently canceled by USMLE.

The competency of the candidate is assessed according to their Medical Knowledge, Patient Care through History and Physical Exam, Patient Care through Laboratory and Diagnostic Studies, Patient Care through Diagnosis, Patient Care through Prognosis and Outcome, Patient Care through Health Maintenance and Disease Prevention, Patient Care through Pharmacology, Patient Care through Clinical Interventions, Patient Care through Mixed Management, Professionalism, and Systems-based Practice.

The section has a maximum of 318 questions in a multiple-choice format. These questions have been divided into eight 60-minute blocks where each block will have a maximum of 40 questions. It is conducted as a one-day examination within a nine-hour-long session. The candidates taking the examination will receive at least a 45-minute break in between the exams. The content for this step of the examination focuses only on clinical science and considers emerging domains along with the curriculum they generally follow. The content outline of the examination is as follows-

• General Principles of Foundational Science
• Immune System
• Blood and Lymphoreticular System
• Behavioral Health
• Nervous System and Special Senses
• Musculoskeletal System/ Skin and Subcutaneous Tissue
• Cardiovascular System
• Respiratory System
• Gastrointestinal System
• Renal and Urinary System and Male Reproductive System
• Pregnancy, Childbirth, and the Puerperium
• Female Reproductive System and Breast
• Endocrine System
• Multisystem Processes and Disorder
• Biostatistics and Epidemiology/ Population Health/ Interpretation of Medical Literature
• Social Sciences: Legal/ Ethical Issues and Professionalism/ Systems-based Practice and Patient Safety

Step 3 of USMLE

This is the final step of the USMLE and assesses the knowledge the candidate has in biomedical and clinical science which can be used in the unsupervised practice of medicine. This exam is conducted as a foundation for an independent practice where physicians will be required to function under pressure within context-specific cases.

The exam is conducted over 2 days the first day is called the Foundation of Independent Practice/ FIP and the second day is called the Advanced Clinical Medicine/ ACM. The general content of the examination is always subject to change but contains an integrated content outline from which students can expect questions.

• General Principles of Foundational Science
• Immune System, Blood, and Lymphoreticular System
• Behavioral Health
• Nervous System and Special Senses
• Musculoskeletal System/ Skin and Subcutaneous Tissue
• Cardiovascular System
• Respiratory System
• Gastrointestinal System
• Renal/ Urinary System and Male Reproductive System
• Pregnancy/ Childbirth and Female Reproductive System and Breast
• Endocrine System
• Biostatistics and Epidemiology/ Population Health/ Interpretation of Medical Literature
• Social Sciences: Legal/ Ethical Issues and Professionalism/ Systems-based Practice and Patient Safety

First Day of Step 3 in USMLE

This exam will contain 232 questions all of which will be a multiple-choice format. These questions will be divided into six blocks with 38-39 questions each. Each block will be given a maximum of 60 minutes to complete. The exam will be conducted in 7 hours with a 45-minute or more break given in between.

Second Day of Step 3 in USMLE

The second day of the examination will be given 9 hours in total with a 45-minute break in between. It contains 180 multiple-choice questions in all which will be divided into 6 blocks each of 30 questions. After this, there will be 13 case simulations for which the candidate will get 10-20 minutes maximum.

USMLE Score Reports

Usually, candidates can access their results two to four weeks following the date of the test. There are several reasons why score reporting could be delayed. It is recommended that candidates allow a minimum of eight weeks for notification of the availability of their score report when scheduling their test and enquiring about the results. The organization that registered candidates for the test will send them an email alert when their results are available. After the date of the email notification, the candidates' score reports will be accessible for about 365 days on the website of the registered organization.
The USMLE results are reported on either a two-digit scale or a three-digit scale except for Step 1 which is accounted for as a Pass/ Fail starting from January 26, 2022. The current pass mark for each of the Steps are as follows-

• Step 2 CK - 214
  
• Step 3 - 198
  

Sending the Score Transcript for USMLE

To send the exam transcript or to send it to a third party, candidates will have to contact the ECFMG, FSMB, or NBME and pay a nominal amount for the same. The details for the institution they have to contact for the transcript will be dependent on the Steps the candidate has taken and the place they want to send it to.

For sending one or more USMLE Steps to the Medical Licensing Authority or any other recipient, they have to send the request to FSMB. For sending all 3 Steps to any recipient they have to request to the FSMB. For sending both Step 1 and 2 while registered under ECFMG, to any recipient other than a Medical Licensing Authority they have to request to ECFMG. And if they want to send Steps 1 and 2 while registered under NBME, to any recipient other than a Medical Licensing Authority they have to request NBME.

USMLE Test Centers

Candidates must go to the Prometric website in order to learn the locations of the test centers in a given area. For the USMLE, there will be a "Locate" option under each step. Candidates will be redirected to a new page after clicking the link, where they will be required to enter their address, city, and zip/postal code. They will then be prompted to choose a start and end date. Keep in mind that the end date must fall within two weeks of the chosen start date. Candidates will find the list of test centers in their area after completing these steps.

Rescheduling the Test

On the Prometric website, candidates can reschedule their exams. If USMLE examinees reschedule, cancel, or change the test center location at Prometric Test Centers forty-five days or less prior to their scheduled test date, Prometric will charge a fee. If a test appointment is changed 46 days or more before the scheduled test date, there is no fee. Candidates must ensure that their rescheduled test date(s) falls within their allocated eligibility period when rescheduling. The cost to reschedule the test for a different time period is displayed in the table below:

Date	Testing region	Step 1	Step 2 CK	Step 3
46 or more days before (but not including) the first day of the scheduled test date	All testing regions	No Fee	No Fee	No Fee
31-45 days and before (but not including) the first day of the scheduled test date	All testing regions	$35	$35	$35
6-30 days before (but not including) the first day of the scheduled test date	All testing regions	$100	$100	$100
5 or fewer days before (but not including) the first day of the scheduled test date	US and Canada	$137	$155	$275*
5 or fewer days before (but not including) the first day of the scheduled test date	Outside the US and Canada	$352	$396	N/A

* For Step 3 administrations, candidates will be charged a $138 rescheduling fee if they reschedule one or more, but not all, days of their appointment between 1 and 5 days prior to their first scheduled test date.

Requesting Additional Break Time

Through the USMLE website, candidates can apply for extra break/standard testing time by filling out the form. They will only be permitted to do so for medical reasons. Requests for longer breaks should be submitted either before or at the time of registering for the Step exam. Examinees should be aware, however, that if they take an additional break, Step 2 turns into a two-day exam and Step 3 becomes a three-day exam.

Top Medical Schools

The best schools that can help the candidate prepare for the USMLE in the US are as follows-

• Harvard University, Boston, MA
• Johns Hopkins University, Baltimore, MD
• University of Pennsylvania, PA
• Stanford University, Stanford, CA
• University of California, San Francisco, SA
• Washington University, St. Louis, MO
• Yale University, New Haven, CT
• Columbia University, New York, NY
• Duke University, Durham, NC
• University of Chicago, Chicago, IL

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