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). Physicians with an MD degree are required to pass this examination before being permitted to practice medicine in the United States unsupervised Individual states often add their own additional requirements.) Physicians with a Doctor of Osteopathic Medicine (DO) degree are permitted to take either the USMLE or the Comprehensive Osteopathic Medical Licensing Examination (COMLEX) exam for medical licensure.
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.
History.
The USMLE was first designed in the late 1980s and introduced during the period 1992 to 1994. The program replaced the NBME Part Examination program and the FSMB's Federation Licensing Examination (FLEX) program, which were the widely accepted medical licensing examination programs at the time in the medical profession. In 2004, a clinical-skills examination was added to Step 2 of the USMLE (USMLE Step 2 Clinical Skills, and beginning with the medical school graduating class of 2005, students have been required to pass it in order to be licensed. In 2005, a clinical-skills component was also added to the examination program of the Comprehensive Osteopathic Medical Licensing Examination of the National Board of Osteopathic Medical Examiners, which physicians with the D.O. degree take to achieve medical licensure in the United States. 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." On January 26, 2021, the USMLE announced that the work to relaunch a modified form USMLE Step 2 CS had been discontinued citing rapidly evolving medical education and changes in other standardized exams, like computer-based simulations in Step 3, that would supplement medical students' education in place of Step 2 CS. 
Steps.
The USMLE comprises three steps, all of which 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. 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.
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: 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 be 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 (tier of hospital) for which a residency applicant is competitive.
In recent years, an applicant's Step 1 score has been cited by medical 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 emphasis. 
Average USMLE Step 1 scores for various residencies are available in Charting Outcomes in the Match. 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.
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 the Step 2 Clinical Knowledge test, as well as put international medical graduates (IMGs) at a disadvantage, as traditionally IMGs strive to score 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 between the third and fourth year of medical school. Step 2 is divided into two separate exams: Step 2 CK & Step 2 CS:
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:
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 was discontinued in 2021. It contained the following subjects:
Step 2 CS used 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 was 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.
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."
On January 26, 2021, the USMLE discontinued Step 2 CS.
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 announced a move to a pass/fail model on February 12, 2020 along with other changes due to an attempt by the Federation of State Medical Boards (FSMB) and the National Board of Medical Examiners (NBME) 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 using a question bank to prepare for the test.
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 (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. 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.
Controversies.
USMLE response to COVID-19.
The USMLE was met with heavy criticism for their lack of adaptability during the COVID. The criticism was two-fold: First, for the mishandling and poor communication of exam cancellations by both USMLE program administrators and the third-party exam administrator, Prometric. Second, the pandemic crisis exacerbated existing resentment towards the high-stakes nature of the exam: namely, several students and physicians were upset that the USMLE refused to move up the 2022 deadline of making Step 1 into a pass or fail exam.
Exam Cancellations.
Students received little to no information or, in some cases, contradictory information about whether their examination appointments would be upheld. Medscape in an article entitled "USMLE Testing Chaos May Harm Current and Future Doctors" reports:
Earlier Implementation of Pass/Fail.
Some 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. Students signed a letter of concern "detailing their concerns and offering alternatives".
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 (pass/fail or scored) beginning with the class of 2021.
Racial Bias in Using USMLE Step 1 Scores to Grant Residency Interviews.
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 (223) as compared to black and Hispanic applicants (216). 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." 
Financial consideration.
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: