United States Medical Licensing Examination


The United States Medical Licensing Examination is a three-step examination for medical licensure in the United States and is sponsored by the Federation of State Medical Boards and the National Board of Medical Examiners. Physicians with an MD degree are required to pass this examination before being permitted to practice medicine in the United States. See below for requirements of physicians with a DO degree.
During COVID-19 pandemic and George Floyd Protests, the medical community criticized the USMLE for their refusal to revert Step 1 scoring to pass/fail before 2022 and for the gross mishandling of Step examinations during the pandemic, creating "chaos," further "disadvantages," "harm," "bias" and "inequity;" and called for an emergency committee who could address these issues in a timely manner without financial or other conflict of interests.
Current recommendations under consideration include retroactive step 1 pass/fail reporting for the class of 2022, or having each student choose how their Step 1 score is reported on their ERAS transcript beginning with the class of 2021.

Purpose

The USMLE assesses a physician's ability to apply knowledge, concepts, and principles, and to determine fundamental patient-centered skills that are important in health and disease and that constitute the basis of safe and effective patient care. Examination committees composed of medical educators and clinicians from across the United States and its territories create the examination materials each year. At least two committees critically appraise each test item or case, revising or discarding any materials that are in doubt.

Steps

All three steps of the USMLE exam must be passed before a physician with an M.D. degree is eligible to apply for an unrestricted license to practice medicine in the United States. U.S. osteopathic medical school graduates are permitted to take either the USMLE or the Comprehensive Osteopathic Medical Licensing Examination exam for medical licensure. Students who have graduated from medical schools outside the US and Canada must pass all three steps of the USMLE to be licensed to practice in the US, regardless of the title of their degree.
Years of dataU.S. M.D. medical school graduatesU.S. D.O. osteopathic medical school graduatesInternational medical school graduates
Step 194%96%93%93%72%78%
Step 2 CK94%96%92%92%71%75%
Step 2 CS96%96%90%90%78%80%
Step 398%98%90%90%78%80%

Step 1

assesses whether medical school students or graduates understand and can apply important concepts of the basic sciences to the practice of medicine. Step 1 ensures mastery of not only the sciences that provide a foundation for the safe and competent practice of medicine in the present, but also the scientific principles required for maintenance of competence through lifelong learning. Step 1 is constructed according to an integrated content outline that organizes basic science material along two dimensions: system and process. It includes the following subjects: Anatomy, Behavioral Sciences, Biochemistry, Microbiology, Pathology, Pharmacology, Physiology, and
interdisciplinary topics such as nutrition, genetics, and aging.
Step 1 is a one-day examination. It is divided into seven 60-minute blocks and administered in one 8-hour testing session. The number of questions per block on a given examination form will vary, but will not exceed 40. The total number of items on the overall examination form will not exceed 280. US medical students take Step 1 at the end of the Basic Sciences portion of the curriculum, usually after the second year of medical school. If the student passes the exam, he or she may not repeat it to achieve a higher score, and any failed attempt is permanently recorded. This situation of the Step 1 exam being a "one-time deal" is the reason it is broadly viewed as the most arduous and paramount examination a medical student will ever sit during his or her career. Its three-digit result has substantial bearing on the specialties and location for which a residency applicant is competitive.
In recent years, an applicant's Step 1 score has been cited by residency program directors as their most important criterion in selecting graduating medical students for their residency program, despite lack of evidence or data to support that perversion.
Average USMLE Step 1 scores for various residencies are available in . The current use of Step 1 scoring as a major determinant for granting residency interviews has been met with tremendous criticism by the medical community, citing that the Step 1 exam was intended to be one of four licensing tests. It was never designed to be a predictor of medical knowledge for which cutoffs or barriers could be justified, and instead enables racial bias.
In response to public outcry, in February 2020, the USMLE program announced a plan to change Step 1 score reporting to a pass/fail system in an effort "to reduce overemphasis on Step 1 performance while allowing licensing authorities to continue the original intention to use the test to determine medical license eligibility. "
However, this transition will occur no earlier than January 1, 2022. The USMLE wrote on their site, "Changing Step 1 score reporting to pass/fail can help reduce the current overemphasis on USMLE performance, while retaining the ability of medical licensing...This change is an important first step toward facilitating broader, systemic change. However, critics of this decision argued that this would just shift the importance of the three-digit number score on to Step 2 CK, as well as putting international medical graduates at a disadvantage, as traditionally IMGs scored exceptionally high on Step 1 in order to distinguish themselves and obtain residency positions in coveted specialties or hospitals.
During the COVID-19 pandemic, the USMLE wrote on their COVID-FAQ page and on twitter that despite receiving many inquiries to move to immediate pass/fail, they would not consider any early changes to STEP 1 reporting as this would affect their "stakeholders."
As of June 2020, the USMLE has not yet decided how the STEP 1 will be reported on the ERAS transcripts for the Class of 2022 or later when applying to residency. The USMLE wrote on their website that if you received a score on the STEP before 2022, the "USMLE program has not yet determined how the policy change will impact score reports and transcripts."

Step 2

USMLE Step 2 is designed to assess whether medical school students or graduates can apply medical knowledge, skills and understanding of clinical science essential for 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. US medical students typically take Step 2 during the fourth year of medical school. Step 2 is further divided into two separate exams:

Step 2 CK

is a one-day examination. It is divided into eight 60-minute blocks, administered in one 9-hour testing session. Test item formats may vary within each block. It is constructed according to an integrated content outline that organizes clinical science material along two dimensions: physician task and disease category. It includes the following subjects:
internal medicine,
obstetrics and gynecology,
pediatrics,
preventive medicine,
psychiatry,
surgery,
other areas relevant to provision of care under supervision.

Step 2 CS

The USMLE Step 2 Clinical Skills exam contains the following subjects:
Step 2 CS uses standardized patients to test medical students and graduates on their ability to gather information from patients, perform physical examinations, and communicate their findings to patients and colleagues. The examination is offered in five U.S. cities: Philadelphia, Chicago, Atlanta, Houston, and Los Angeles.
Administration of the Step 2-CS began in 2004. Prior to 2004, a similar exam, the Clinical Skills Assessment was used to assess the clinical skills of foreign medical graduates.
On May 26, 2020, in response to the COVID-19 pandemic, the USMLE "suspended Step 2 CS test administrations for the next 12-18 months."

Step 3

USMLE Step 3 is the final exam in the USMLE sequence and assesses whether medical school students or graduates can apply medical knowledge and understanding of biomedical and clinical science essential for the unsupervised practice of medicine, with emphasis on patient management in ambulatory settings. Graduates of US medical schools typically take this exam at the end of the first year of residency. Examinees are tested on the following subjects:
central nervous system, eye/ear/nose/mouth/throat, respiratory system, circulatory system, digestive system, behavioral/emotional disorders, musculoskeletal system, skin/subcutaneous tissue, endocrine/nutrition/metabolic disorders, kidneys/urinary tract, reproductive system, pregnancy/childbirth, neonate/childhood illnesses, blood and blood-forming organs, infectious/parasitic diseases, injuries/wound/toxic effects/burns, and health maintenance issues.
Step 3 is a two-day examination. The first day of testing includes 233 multiple-choice items divided into 6 blocks of 38-40 items; 60 minutes are allotted for completion of each block of test items. Items with an associated pharmaceutical advertisement or scientific abstract are included in each of these multiple-choice blocks. There are approximately 7 hours in the test session on the first day.
There are approximately 9 hours in the test session on the second day. This day of testing includes 180 multiple-choice items, divided into 6 blocks of 30 items; 45 minutes are allotted for completion of each block of test items. This is followed by 13 case simulations, each of which is allotted a maximum of 10 or 20 minutes of real time.

Test Sites and Preparation

The USMLE Step 1 and Step 2 CK exams can be taken at Prometric test centers worldwide. The Step 2 CS and the Step 3 can only be taken in the United States.
The USMLE Step 1 is typically taken during a student's second year of medical school. The one-day exam tests them on basic science principles, including behavioral science, microbiology, physiology, and anatomy. The exam moved to a pass/fail model on February 12, 2020 along with other changes due to an attempt by the Federation of State Medical Boards and the National Board of Medical Examiners to balance focus between exams and actual coursework.
USMLE mean and median scores have increased significantly in the past decades—so much so that the testing board had to increase the score it takes to pass. A large part of the increase was attributed in empirically-based research articles to performance improvement factors such as a bank. A study commenced by the University of Florida College of Medicine stated that "The United States Medical Licensing Examination Step 1 plays a pivotal role in one’s residency application. While prior literature has investigated which factors influence performance on the examination, the authors sought to include factors such as performance on a well-used question bank and financial need to develop a predictive model. Method After obtaining institutional review board approval, the authors surveyed two consecutive second-year medical school classes and correlated the data to the students’ Step 1 and National Board of Medical Examiners Comprehensive Basic Science Examination scores. The survey included questions such as how many days they studied per week, how many days they studied in total, which resources they used, how they performed on question banks, group studying habits, and whether they were receiving financial aid. The authors also assessed whether the students received only A letter grades during the first year of medical school. The authors used SPSS® Statistics V22.0 and included one-way analysis of covariance and multiple linear regression for statistical analysis. Results Eighty-one students completed the survey with an average Step 1 score of 240.5 and with an average study time of 39.5 days. The Step 1 Scores significantly correlated with the CBSE taken immediately preceding the dedicated study period, UWorld Question Bank percentage correct, straight As during first-year, and financial need. The scores were not correlated with age, gender, Medical College Admissions Test, prior medical training, number of days studied, or the students’ perception of appropriate time studied. The authors developed a predictive model accounting for 62.3% of the variability. 140.625+-++, where A=1 if straight As, N=1 if receiving need-based scholarship, U=UWorld percent-correct, and CBSE=the three-digit score of the CBSE taken prior to the dedicated study period. Conclusions Academic performance and financial need may predict Step 1 scores. Interestingly, the number of days studied did not have a correlation with scores, suggesting that increased length of study may not ameliorate poor grades."

Relevance of predictive measures

A study from 2016 showed little to no correlation between MCAT scores and USMLE step 1 scores, as well as little to no correlation between MCAT scores and the NBME scores. However, since the 82 students on whom this study was conducted all attended the same medical school, the usefulness of these results in the broader medical school population may be of limited value.
Furthermore, research conducted on students between 1998 and 2004, although outdated, and conducted on an undisclosed number of students, was conducted on a longer timeline, and shows that the Biological Science section of the MCAT did indeed predict better performance on the USMLE step 1, but not any other section, and found that Grade point average in undergraduate science courses is a strong predictor of performance on the USMLE step 1 and step 2 exams, and that the Biological Science section of the MCAT, but not any other section, predicted USMLE step 1 and step 2 exam performance, though this information is outdated, and unclear of whether this was also only conducted at a single institution or more than one, making this study's results of limited value. The same study claims that the selectivity of undergraduate institution is also a predictor of step 1 and step 2 performance, even when controlling for undergraduate GPA and MCAT score.

USMLE mishandling during COVID-19

With the ongoing COVID-19 pandemic, the USMLE and NBME were met with tremendous criticism by the medical community--including their parent organizations AMA and AAMC as well as letters and petitions from physicians and students-- for lack of flexibility and adaptability during COVID and for mishandling testing and refusing to revert step 1 scoring pass/fail before 2022.
A summary of current complaints surrounding the USMLE mishandlings can be found and include the USMLE's "failure to take responsibility," "lack of communication," "day-of cancellations," and unequal access for test takers that created "inequity," "bias," "chaos" and "harm" to students and "shortchanging their clinical experience."
By not reverting to remote P/F during COVID, the USMLE is "distracting students from their medical education," said a doctor at a Standford. Because of overemphasize of Step 1, students study for months, often at the expense of classes and clinical training. These further delays will further exacerbate that problem. For the few that were able to test during COVID, many of those students reported taking a day or more off of clinical rotations to fly to their exam, only to find out their exam was cancelled day-of and had to scramble for a new date months later, meaning they would miss more months of their medical education to study for Step 1.
The medical community was upset that despite the chaos, harm, and damages to the integrity of the test created by USMLE, the USME's concern was their stakeholders, not students. Despite numerous letters, petitions on change.org and the medical community's public pleas, Michael Barone, VP of NBME Licensure Programs, said that the USMLE would not consider moving up the anticipated pass/fail Step 1 scoring before 2022 because it would affect their "stakeholders". The medical community was upset that the USMLE prioritized residency programs over students and doctors. The Step scores were not designed to be used as a residency admissions metric; the scores we intended for medical licensing purposes only and have no meaning beyond pass/fail designation. While it is ultimately the Residency programs fault for misusing the step scores, the USMLE/NBME are aware of and directly enabling the misuse. The overemphasis of Step would not occur if the exam was scored as originally intended.
The resulting "harm and chaos" has created inequity and bias and damaged the integrity of the Step exams. To have the most "unbiased and equitable" exam, the medical community has asked the AAMC, ERAS, and USMLE to allow medical students to choose how their score would be reported on their ERAS transcript during this transition or retroactively report scores as pass/fail beginning with the class of 2022. To avoid the potential financial conflict of interest of the NBME and USMLE, the Coalition for Physician Accountability launched workgroups to address the downstream implications of COVID-19.
Numerous memes have gone viral regarding these matters.

Controversies

USMLE response to COVID

The USMLE was met with heavy criticism for their lack of adaptability during the COVID.
Students and physicians were upset that the USMLE refused to move up the 2022 deadline of making Step 1 pass or fail, in light of the testing barriers created by COVID. The USMLE responded that the "eventual change to Pass/Fail score reporting for Step 1 will impact their stakeholders," implying their stakeholders were not students.

Racial Bias of Step 1 scoring

Research demonstrates some differences in USMLE scores attributable to race and ethnicity, with self-identified Black, Asian, and Hispanic examinees showing score differences when compared with self-identified White examinees. "The mean USMLE step 1 score was significantly greater among white applicants as compared to black and Hispanic applicants. Depending on the threshold score, an African American was 3-6x less likely to be offered an interview."
"61% of minority applicants were accepted into an orthopaedic residency versus 73% of White applicants. White and Asian applicants and residents had higher USMLE Step 1. White applicants and matriculated candidates had odds of Alpha Omega Alpha membership compared with Black, Hispanic, and Other groups.
One of the recommendations for Step 1 changing to pass or fail was to address racial differences. "Among self-identified racial groups, research shows that white students perform higher on the USMLE than any other group."
The American Academy of Family Physicians and Association of American Medical Colleges supported changing Step 1 to pass or fail to reduce racial bias.

Katsufrakis & Chaudhry comments against Step 1 changes

In Dec 2018, NBME President Peter Katsufrakis and FSMB President Humayun Chaudhry wrote in opposition of USMLE Step 1 changes in from Improving Residency Selection Requires Close Study and Better Understanding of Stakeholder Needs:
"If students reduce time and effort devoted to preparing for Step 1, they may indeed devote attention to other activities that will prepare them to be good physicians. This would arguably be an ideal outcome of such a change. However, if students were to devote more time to activities that make them less prepared to provide quality care, such as binge-watching the most recent Netflix series or compulsively updating their Instagram account, this could negatively impact residency performance and ultimately patient safety. We know that assessment drives learning, so another concern resulting from a shift to pass/fail scoring may be a less knowledgeable physician population."

NBME Executive Salary

The NBME executives received public criticism after their salaries were released after increasing costs for students, showing many executives receiving high said to seven figures.
"Former NBME President Dr. Melnick's compensation increased from $399,160 in 2001 to over $1.2 million in 2016, almost perfectly in parallel with the tripling of USMLE costs." "As of 2016, NBME President also gets free first-class airfare for himself and his travel partner, as well as a membership to a Philadelphia social club. According to the 2017 Form 990, Schedule J, two lower executives received total compensation over $700,000; another two over $600,000; another three receiving over $500,000; and another 6 receiving over $400,000....Yet, the total number of test-takers for the USMLE Step 1 has been essentially unchanged for the past 10-15 years."

Pricing

USMLE was met with criticism when they announced their raising cost for STEP standardized tests.
Kevin MD wrote, "Safeguards are needed to ensure fees for mandatory testing such as the USMLE do not exceed reasonable operating costs, particularly for financially vulnerable medical students."
As part of a broader public plea for systemic changes to the improper use of USMLE STEP exams, STAT wrote that this "multimillion-dollar industry has exploited the opportunity to extract thousands of dollars from already overly indebted students. Registering for STEP exams test cost $645-$1300, while Step preparation materials and courses run much higher."
As of 2020, the USMLE currently charges: