United States Medical Licensing Examination

The United States Medical Licensing Examination (USMLE) is a three-step examination for medical licensure in the United States and is sponsored by the Federation of State Medical Boards (FSMB) and the National Board of Medical Examiners (NBME).[1] 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.


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.[2]


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 (COMLEX) 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.

Overall pass rates for the individual Step exams that comprise the USMLE[3]
Years of data U.S. M.D. medical school graduates (US 1st-time takers) U.S. D.O. osteopathic medical school graduates (US DO 1st time) International medical school graduates (Int'l 1st time)
Step 1 (2015) 94% 96% 93% 93% 72% 78%
Step 2 CK (2014-2015) 94% 96% 92% 92% 71% 75%
Step 2 CS (2014-2015) 96% 96% 90% 90% 78% 80%
Step 3 (2015) 98% 98% 90% 90% 78% 80%

Step 1

USMLE 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:[4] Anatomy, Behavioral sciences, Biochemistry, Microbiology, Pathology, Pharmacology, Physiology, 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. The Step 1 score is frequently used in medical residency applications as a measure of a candidate's likelihood to succeed in that particular residency (and on that specialty's board exams), and it has been cited by residency program directors as their most important criterion in selecting graduating medical students for their residency program.[5] Average USMLE Step 1 scores for various residencies are available in Charting Outcomes in the Match.

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 "one-time deal" situation is the reason the Step 1 is broadly viewed as the most arduous and paramount examination a medical student will ever sit during his or her career. It has substantial bearing on the specialties and location a residency applicant is competitive for.

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

USMLE Step 2 Clinical Knowledge 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:[6] 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:

  • Integrated Clinical Encounter (ICE)
  • Communication and Interpersonal Skills (CIS)
  • Spoken English Proficiency (SEP).[7]

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 (CSA) was used to assess the clinical skills of foreign medical graduates.

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.[8]

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

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 USA.

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.[9] 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.[9]

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 (BS) 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.[10] 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.[10]

Similar exams

  • The "Comprehensive Osteopathic Medical Licensing Examination" (COMLEX-USA) is required for osteopathic physicians in the United States
  • The American Podiatric Medical Licensing Examination (APMLE) is required for Podiatric Physicians in the United States.

In other countries


  1. "United States Medical Licensing Examination ®". www.usmle.org. Retrieved 2016-08-18.
  2. "United States Medical Licensing Examination | USMLE Bulletin". www.usmle.org. Retrieved 2016-08-18.
  3. "United States Medical Licensing Examination | Scores & Transcripts". www.usmle.org. Retrieved 2016-08-18.
  4. https://usmle.org/step-1/
  5. Archived December 16, 2011, at the Wayback Machine
  6. https://usmle.org/step-2-ck/
  7. https://usmle.org/step-2-cs/
  8. https://usmle.org/step-3/
  9. Giordano, C., Hutchinson, D., & Peppler, R. (2016). A Predictive Model for USMLE Step 1 Scores. Cureus, 8(9), e769. http://doi.org/10.7759/cureus.769
  10. Kleshinski, James; Sadik A. Khuder; Joseph I. Shapiro; Jeffrey P. Gold (7 November 2007). "Impact of preadmission variables on USMLE step 1 and step 2 performance" (PDF). Advances in Health Sciences Education. Springer. 14: 69–78. doi:10.1007/s10459-007-9087-x. Retrieved August 22, 2010.

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