United States Medical Licensing Examination

The United States Medical Licensing Examination (USMLE) is a three-step examination program for medical licensure in the United States sponsored by the Federation of State Medical Boards (FSMB) and the National Board of Medical Examiners (NBME).[9] Physicians with a Doctor of Medicine (MD) degree are required to pass the USMLE for medical licensure. However, those with a Doctor of Osteopathic Medicine degree (DO) are required to take the COMLEX-USA (COMLEX) exams.[10][11]

United States Medical Licensing Examination
AcronymUSMLE
TypeComputer-based, three-part sequence, standardized test
Developer / administratorFederation of State Medical Boards, National Board of Medical Examiners
Knowledge / skills testedSTEP 1: Application of scientific principles basic to the practice of medicine
STEP 2: Application of medical knowledge, skills, and understanding of clinical science essential for supervised patient care
STEP 3: Application of medical knowledge and understanding of biomedical and clinical science essential for the unsupervised practice of medicine
PurposeMedical licensure in the United States
Year started1992 (1992)
DurationSTEP 1: 8 hours[1]
STEP 2: 9 hours[2]
STEP 3 (Day 1): 7 hours
STEP 3 (Day 2): 9 hours[3]
Score / grade rangeSTEP 1: pass/fail
STEP 2: 1-300 (214 to pass)[4]
STEP 3: 1-300 (198 to pass)
OfferedYear round
Countries / regionsGlobally at a Prometric centers for Step 1 and Step 2 CK; at a U.S. Prometric centers for Step 3
LanguagesEnglish
Annual number of test takersMore than 100,000 medical school students and graduates (2020)[5][6]
FeeSTEP 1: US$645.00
STEP 2: US$645.00[7]
STEP 3: US$895.00[8]
Scores / grades used byState medical and osteopathic boards in the U.S. and U.S. Territories
Websitewww.usmle.org

States may enact additional testing and/or licensing requirements.[12]

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.[13] The program intends to provide state medical boards in the United States with a common examination for all licensure applicants.[14] Physicians with an M.D. degree are required to take the USMLE, but those with a D.O. degree take the COMLEX to qualify for state licensure.[10]

History

The USMLE was first designed in the late 1980s and introduced during the period 1992 to 1994. The program replaced the multiple examinations, including the NBME Part Examination program and the FSMB's Federation Licensing Examination (FLEX) program, that offered paths to medical licensing in the medical profession.[15] The United States Medical Licensing Examination (USMLE) must be passed before a physician with a Doctor of Medicine (M.D.) degree can obtain a license to practice medicine in the United States.[16]

In 2004, a clinical-skills examination was added to Step 2 of the USMLE, and beginning with the medical school graduating class of 2005, students have been required to pass it in order to be licensed.[17]

In 2009, the FSMB's Board of Trustees adopted a board report on a comprehensive review of the USMLE program.[18] Major recommendations from this strategic review included more explicitly orienting the USMLE examination to support the licensing decisions made by medical boards, transitioning the exam to a competencies schema and emphasizing the importance of scientific foundations of medicine throughout the examination sequence.

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."[19] 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.[20]

Step examinations

The USMLE program is composed of three examinations:[21][22]

  • Step 1
  • Step 2 CK
  • Step 3

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:[23] Anatomy, Behavioral Sciences, Biochemistry, Microbiology, Pathology, Pharmacology, Physiology, and interdisciplinary topics such as nutrition, genetics, and aging.

Step 2 CK
Main article: USMLE Step 2 Clinical Knowledge

USMLE Step 2 Clinical Knowledge is a standardized test that assesses a candidate's ability to apply medical knowledge, skills, and understanding of clinical science essential for the provision of patient care under supervision[24] covering topics in various medical disciplines: internal medicine, obstetrics and gynecology, pediatrics, psychiatry and surgery.[25]

Step 2 CS (discontinued)
Main article: USMLE Step 2 Clinical Skills

The USMLE Step 2 Clinical Skills exam was a standardized test that assessed candidates on their ability to gather information from patients, perform physical examinations, and communicate their findings to patients and colleagues. It was discontinued in 2021.[26][19]

Step 3
Main article: USMLE 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.[27] 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/wounds/toxic effects/burns, and health maintenance issues.[28]

Pass rates by exam
Overall pass rates for the individual Step exams that comprise the USMLE[29]
Years of data U.S. M.D. medical school examinees (US 1st-time takers) U.S. D.O. osteopathic medical school examinees (US DO 1st time) Examinees from Non-US/Canadian Schools (Int'l 1st time)
Step 1 (2021) 95% 96% 94% 94% 77% 82%
Step 2 CK (2020-2021) 98% 99% 98% 98% 88% 91%
Step 3 (2021) 97% 98% 97% 97% 87% 91%
Further information: Comparison of MD and DO in the United States

Test sites and preparation

The USMLE Step 1 and Step 2 CK exams can be taken at Prometric test centers worldwide. The Step 3 can only be taken in the United States.[30]

The USMLE Step 1 is typically taken during a student's second year of medical school.[31] 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.[32]

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.[33] 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.[33]

Power 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.[34] 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.[34]

Furthermore, research conducted on students between 1998 and 2004, although outdated, and conducted on an undisclosed number of students, was carried out 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 as to whether this was also only conducted at a single institution or more than one, making this study's results of limited value.[35] 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.[35]

Controversies

USMLE response to COVID-19

The USMLE was met with criticism for their lack of adaptability during the COVID-19 pandemic. 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.[36][37][38][39]

Racial differences in outcome associated with the use of USMLE Step 1 scores to grant residency interviews

A study conducted in 2020 showed differences in USMLE Step 1 scores attributable to race and ethnicity, with lower mean scores for self-identified Black, Asian, and Hispanic examinees when compared with self-identified White examinees. The mean effect was larger when comparing Caucasian applicants (223) with Black and Hispanic applicants (216).[40] Depending on the threshold score, an African American was 3-6x less likely to be offered an interview."[41] "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 higher odds of Alpha Omega Alpha membership compared with Black, Hispanic, and other groups.[42][43] [44][45] In year 2020, the American Academy of Family Physicians and the Association of American Medical Colleges expressed their support for changing Step 1 to pass or fail, in part to reduce racial bias.[46][47][48]

Financial considerations

The US Medical Licensing Examinations have received criticism due to their high cost. As of 2020, the USMLE charges:

  • $645 for Step 1 for US students,[49] $975 IMG[50]
  • $645 for Step 2 CK US students,[49] $975 IMG[50]
  • $895 for Step 3 for US students and IMGs[51]

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."[52]

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

References
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  3. "Step 3 Exam Content | USMLE".
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