Guide to the USMLE

September 12, 2014

Article by Global Pre-Meds
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A student examining samples in the hospital lab.Before you can become licensed as a physician, you will need to pass the United States Medical School Licensing Exam (USMLE). Although exams, such as the USMLE, can be nerve-wracking, learning what is involved and how to prepare can take some of the stress away and get you one step closer to becoming a doctor.

Basics of taking the USMLE

The USMLE is a computer-based exam, which is taken in three parts. The first two parts are taken while still in medical school as part of the process for becoming licensed as a physician. The third part is taken just after graduation from medical school. The exam is administered in order to ensure that doctors are qualified and competent to practice medicine before they are granted a license.

To be eligible for the exam, you must be a medical student enrolled in a medical school accredited by the Liaison Committee on Medical Education. Students enrolled in a DO degree program accredited by the American Osteopathic Association are also eligible to take the USMLE. Students within the United States apply to take the exam through the National Board of Medical Examiners (NBME). For the latest information on the exam fee, check the NBME website.  


Similar to taking other big exams, preparation and organization are the keys to success on the USMLE.  Although the National Board of Medical Examiners does not sanction any test preparation classes, there are some private companies which offer prep classes.

Reviewing subject areas covered on the exam and then answering sample questions may help you identify what areas you need to brush up on. Consider starting or joining a study group related to the USMLE a few months before scheduling the exam to refresh your memory on key concepts. Practice test materials and sample questions are also available through the United States Medical School Licensing Exam website.

Taking Step One of the USMLE

Although there is not an exact point at which students must take the USMLE, most students take step one of the exam between their second and third years of medical school before clinical rotations start.

Although not every student may agree, step one of the test is considered to be the most difficult of the three-part exam. Step one scores are also considered when residency program directors are awarding residencies.

Step one tests students on their knowledge of science. The exam is comprised of 322 multiple choice questions on a variety of subject areas including biochemistry, pathology and pharmacology. It also covers behavior sciences, anatomy, microbiology and physiology. Questions will also include interdisciplinary topics, such as genetics, nutrition and aging.

Exam content also involves the identification of pathological and normal microscopic specimens. Students will be asked questions that require applying science knowledge to clinical problems.

Step one of the USMLE is divided into seven blocks. Students have one hour to complete each block. It is important to understand that after you exit out of a particular block, you cannot go back and review that content area and answers cannot be changed.  Before moving on to the next block, students should be sure they are satisfied with their answers.

Moving on to step two of the USMLE

Step two of the USMLE tests students on whether they can apply their knowledge to caring for patients under the supervision of a physician. It involves two separate tests administered over two days. Step two clinical knowledge (CK) tests students on areas including surgery, internal medicine and pediatrics. Obstetrics and gynecology along with psychiatry and preventive medicine are also covered.

This portion of the exam consists of 355 multiple choice questions. Questions related to diagnosis, prognosis, the next steps in medical care and preventive measures may be asked. Students will also be asked questions on diseases of different biological systems, such as the respiratory and cardiovascular system. Exam questions may also involve mental, gynecological and endocrine disorders.

Similar to step one of the exam, the test is administered in one hour blocks. There are eight blocks. Although you can answer questions in any order in a block and change answers, once you leave a block you cannot go back. 

The second part of the test is called the clinical skills (CS) portion of the exam. It will test your ability to gather information, document findings, and share information. How well you develop rapport and display a professional manner with patients is also evaluated.

Step two CS is a different format than the other steps. It involves using people who are trained to portray patients for the purpose of the exam. Students will see 12 different patients and have 15 minutes with each patient.

During that time, students will need to establish rapport, gather a medical history, and perform a focused physical exam. They will also have to answer any patient questions. After their time with each patient, test takers have ten minutes to record findings and diagnostic impressions along with their outline for care. Step two of the USMLE is often taken in the fourth year of medical school. You will need to pass step one and two before moving on to step three of the exam. 

The homestretch: step three

The bad news is that there is another step of the USMLE, which needs to be taken before you can become licensed as a physician. The good news is that you are in the homestretch. Step three is the last past of the USMLE and is taken after graduating from medical school.

Step three of the exam is broken into two eight-hour tests. It covers questions related to clinical encounters, such as urgent interventions and initial workups. Tasks including formulating a diagnosis and developing a treatment plan are also evaluated. Various disease categories are included.  

The exam consists of two categories including multiple choice questions and computer-based patient simulation questions. There are 480 multiple choice questions on the first part of the test. The second part of the exam consists of about 12 different patient simulations, which need to be completed in the order they are presented.