USMLE: United States Medical Licensing Examination, What is it?

The United States Medical Licensing Examination (USMLE) is a series of tests taken in three different steps for board certification. The test is compulsory for every medical graduate to practice medicine in the United States.

USMLE is sponsored by the National Board of Medical Examiners (NBME) and the Federation of States Medical Board (FSMB) to evaluate the medical skills and knowledge of medical graduates.

Doctors with medical degrees need to pass USMLE to get a medical license. Whereas international medical graduates should be certified by the Educational Commission for Foreign Medical Graduates (ECFMG) to enter the fellowship and residency program recognized by the Accreditation Council for Graduate Medical Education (ACGME) in the United States.

The USMLE is different from other medical-related tests because you need to take the test in three different steps during different durations of your degree. Another notable difference is that it evaluates your skills in using medical equipment and not based on the knowledge you have. You need to have a complete knowledge of science and the ability to practice it in the clinic.

Graduates with an Osteopathic medicine degree aren’t required to take USMLE as a whole as most of them only take the first step of the test along with the comprehensive osteopathic medical licensing examination in the US.

What is the US Medical Licensing Test, USMLE?

The United States Medical Licensing Examination test is designed to ensure that the patients are receiving effective and safe medical treatment.

Graduates practice their knowledge while keeping in mind to provide quality care to every patient.

Below we will discuss the three steps of the test:

Licensing Exam    

Step 1: Multiple-Choice Questions (MCQs)

The first step of the test is a one-day test with 8-hour computer-based multiple-choice questions that include the following:

• Seven sections of Multiple-Choice Questions (total 280 MCQs) with allowed time duration of 60 minutes.
• Each section includes a random 40 questions (90 seconds for one MCQ).
• A 45-minute break.
• 15-minute optional tutorial in the beginning.
• The time saved in sections and tutorials is added to the break.

Below is the percentage for each exam discipline and content:

System	Percentage of exam content
General principles	12–16%
Immune systems	7–11%
Nervous system and behavioral health	9–13%
Skin, subcutaneous, and musculoskeletal tissue	6–10%
Heart system	5–9%
Urinary and respiratory system	9–13%
Digestive system	5–9%
Endocrine and reproductive systems	9–13%
Multisystem disorders and processes	6–10%
Biostatistics and epidemiology	4–6%
Communication skills	6–9%

Discipline	Percentage of exam content
Microbiology	10–15%
Histology & cell biology	8–13%
Physiology	25–35%
Genetics	5–9%
Pharmacology	15–22%
Pathology	44–52%
Biochemistry & Nutrition	14–24%
Immunology	6–11%
Gross anatomy & embryology	11–15%
Behavioral sciences	8–13%

Percentage of various tasks and competencies for physicians

Task and competencies for physicians	Percentage of exam content
Patient Care: Diagnosis History/physical examination Diagnosis	20–25%
Interpersonal skills	6–9%
Practicing basic science concepts	60–70%
Practical for learning and progress	4–6%

On 26 January 2022, the score reporting for step one was changed to pass/fail only. A 3-digit scale (range 1-300) is used to evaluate step 1 scores. The minimum passing score during 2023 was 196.

Step 2: Two Individual Exams

This step includes two different tests, one is Clinical Knowledge (CK) test, and the other is the Clinical Abilities (CA) test.

CK test evaluates if the candidate has comprehensive clinical sciences and medical knowledge to offer the patient complete care. Meanwhile, the CA comprises a practical to interview and examine the patient, writing repost and explaining the results to the patient. The CA test evaluates the interpersonal skills of the candidate.

Step 2 is a 9-hour computer-based exam that contains the following.

• A test of 60 minutes with a total of 318 questions divided into 8 blocks.
• Each block has 40 random questions.
• A break for 45 minutes.
• A 15-minute optional tutorial at the beginning.
• The time saved in the test and tutorial is added to the break.

We gathered the percentage for each exam discipline and content in the below table:

System		Percentage of exam content
Universal concepts in fundamental sciences		2–4%
Immune system		3–5%
Blood & and lymph reticular system		4–6%
Behavioral Health		6–8%
Nervous system		6–8%
Legal issues and patient safety	10–15%
Heart system		8–10%
Lung system		7–9%
Intestinal system		7–9%
Urinary and renal system/Male Reproduction		4–6%
Childbirth and pregnancy		4–6%
Breast and female reproduction		4–6%
Endocrine system		4–6%
Multisystem processes and disorders		4–6%
Epidemiology and Biostatics		3–5%
Subcutaneous, skin, and musculoskeletal tissue		6–10%

Discipline	Percentage of exam content
Psychiatry	10–15%
Surgery	25–30%
Pediatrics	20–25%
Medicine	50–60%
Obstetrics & gynecology	10–20%

 Task and competencies for physicians

Task and competencies for physicians	Percentage of exam content
Patient safety and system-based practical	5–7%
Patient care: History and physical exam Laboratory tests Diagnosis Outcome Disease prevention Pharmacotherapy Clinical mediations Mixed management	0% 13–17% 16–20% 5–9% 8–12% 8–12% 6–10% 12–16%
Applying basic medical concepts	0%
Learning and perfection with practice	3–5%
Competence	5–7%

A 3-digit scale is used to report the scores of Step 2 which ranges from 1-300. Since 2023, the minimum score to pass this step of USMLE is 214.

Step 3: Multiple-Choice Exam     

This test evaluates the candidate's skills to use the knowledge and clinical sciences that are required for unofficial medicine practices.

There are no numerical scores for each step. This is either a failure or a pass based on the candidate's communication skills and reporting with the patient.

How to register for USMLE test?

Supply:

• USMLE Preparation Courses

Tools:

• USMLE Live Classes
• USMLE Study Material

Materials: USMLE PDF Study Material USMLE Video Classes

Important Pointers

Before the Test

• Read the USMLE rule of conduct on the website before applying for the test.
• Also, go through the test center rules and regulations available on the Prometric website.
• Make a photocopy of the permit (it can be a soft or a hard copy).
• Candidates must have valid identification papers.
  • Candidates must have a valid passport or driver's license along with photographs. The papers must have the candidate's name that matches the name on the permit, signature, and photograph.
• Candidates must reach the examination center 30 minutes before the test starts.
  • Those candidates who arrive once the test starts will not be allowed to take the test. The candidate will have to reschedule the test with an additional fee.

What to wear on USML test day?

• Wear something comfortable. Bring a jacket or sweater as the examination hall temperature may vary according to the weather.
• Hang the light clothes on the chair if removed for comfort. These clothes are not allowed to be placed on a lap or desk.
• Candidates cannot take off their sweaters or clothes in the examination hall.
• Candidates are not allowed to wear heavy coats, watches, or expensive jewelry in the test center.
• Following security checks will be done at the test center entrance:
  • Fingerprint (electronic)
  • No glasses (except eyesight glasses) and hair clips will be allowed.
  • Metal scanner and detector
  • Sleeves will be pulled up the wrist and pants above the ankle.
  • Pockets will be checked.

Things allowed in the examination room.

• A copy of the permit (it can be a soft or a hard copy)
• An identification card or document
• Lunch, water, and snacks for break time.
• Ear plugs without wire or cable

What to do during the USMLE test?

• Follow all the rules set by the USMLE board and the invigilation staff of the examination center. These include the following:
  • Leave all your personal belongings in your locker and access them only during break hours.
  • Do not bring any unauthorized material into the test room.
  • Do not write anywhere other than the writing paper provided at the Prometric test center.
• As soon as the candidates enter the CIN number in the system, the test time will start.
  • Candidates must not leave the test center before completing the test as it will mark an incomplete test and will get no score report.

Break Time

• Candidates can take a break at any time between the blocks of the test.
  • Candidates can leave the room for a break or remain in their seats. The same entrance security procedure will be followed if the candidate leaves the room.  
• Candidate must report to USMLE board and/or the invigilation staff of the examination center for leaving during the case of any emergency.
  • Unauthorized breaks will not be given extra time.
  • Candidates cannot use mobile phones during unauthorized breaks.
• The total time for the exam will be deducted for unauthorized breaks.

After the Test Ends

• Everyone feels exhausted after the exam.
• It is normal to have a feeling if I did well or not in the exam.
• You should be proud of appearing in the test no matter what your score is.
• Rest, celebrate, and congratulate yourself on this achievement.
• Do not share the exam content with anyone outside.

Conclusion

Not everyone can pass the USMLE examination on the first attempt. However, this can be demotivating, frustrating, and embarrassing but you are not the only one who couldn’t pass on the first attempt. Many students have reattempted the exam, scored well, and started their careers.

Re-strategizing

Plan again to appear in the USMLE.

• Evaluate yourself based on your score to highlight your weak areas.
• Reach out to your medical school's specialists for guidance and support for the future.
• Work with a tutor to work on your weaknesses if still struggling to improve.

Not working with higher strategies involves common problems.

• The difficult thing is to study for the best: Comfortable learning will not make you successful.
• Make sure you spend most of your time reviewing the USMLE-style questions, this will replicate the exam setting and help you answer questions quickly.
• You should record and go over the topics you did not know while reviewing the answers.
• A series of thousand USMLE-style questions is available in different guidebooks, available online and in the market. They are designed for all the candidates.

Re-scheduling the USMLE examination

• Those candidates who have passed the test on the first attempt are not allowed to retake it unless it's important to meet the deadline set by the medical licensing authority.
• One candidate cannot make more than three attempts during a calendar year for the test. If a candidate wants to appear a fourth time, they can only take the test after 12 months of the first attempt or after 6 months of the last attempt.
• Each of the 3 steps of USMLE can be taken four times, after the fourth attempt candidate is not eligible to apply for USMLE in the future.

Most of the US states require to pass all three steps in a predefined time which is mostly 7 years.