United States Medical Licensing Examination

The USMLE was created in the early 1990s. The program replaced the multiple examinations, including the National Board of Medical Examiners Part Examination program and the Federation of State Medical Boards Federation Licensing Examination (FLEX) program, that offered paths to medical licensing in the medical profession. The examination was originally imparted using pencil and paper. In 1999, computerized examination delivery was included. During the COVID-19 pandemic, USMLE Step 2CS was initially suspended and later discontinued. A review of the program was enacted in 2009. USMLE claimed it was done with the intention of orienting the 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. They also aimed to continue the assessment of clinical skill and interpretation of clinical information. In response to concerns about the role of USMLE Step 1 scores in residency selection and the negative impact on medical student mental health, the United States Medical Licensing Examination (USMLE) announced significant changes to the exam in 2020. One of the major changes was the transition to a pass/fail scoring system from the previous three-digit score reporting system. The change was made to encourage a shift in focus from "high-stakes testing" to "learning and individual improvement", as well as to alleviate some of the stress associated with the exam. These changes were implemented starting in January 2022, with the first USMLE Step 1 scores reported in the pass/fail format in February 2022. Generative AI models can now pass all steps of the exam. ==Description and purpose==

The United States Medical Licensing Examination (USMLE) is required for medical licensure in the United States by all graduates of M.D.-granting American medical schools as well as all graduates of international medical schools. • Step 1: Assesses foundational medical science typically obtained during the first two years of medical school • Step 2CK: Evaluates the applicant's knowledge of clinical medicine • Step 3: Assesses the application of clinical knowledge to patient management Previously, USMLE included a clinical skills portion called USMLE Step 2 Clinical Skills. It was discontinued during the COVID-19 pandemic. Step 1 and 2 are typically completed by U.S. medical students during medical school, while Step 3 is usually taken by the end of the first year of residency. While 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. The USMLE is sponsored by the Federation of State Medical Boards (FSMB) and the National Board of Medical Examiners (NBME). They developed it originally to provide state medical boards in the United States with a common examination for all licensure applicants. However, over time it has also been extensively used by residency programs to predict residency performance and screen residents for selection during the National Resident Matching Program. As of 2024, to be eligible for the United States Medical Licensing Examination (USMLE), candidates must meet specific criteria based on the step of the exam they are applying for: Step 1 and Step 2 CK: Candidates must fall into one of the following categories at the time of application and on the day of the examination: • Medical Students or Graduates of U.S. or Canadian MD Programs: • Must be officially enrolled in, or a graduate of, a U.S. or Canadian medical school program leading to the MD degree, accredited by the Liaison Committee on Medical Education (LCME). • Medical Students or Graduates of U.S. DO Programs: • Must be officially enrolled in, or a graduate of, a U.S. medical school program leading to the DO degree, accredited by the Commission on Osteopathic College Accreditation (COCA). • Medical Students or Graduates of International Medical Schools: • Must be officially enrolled in, or a graduate of, a medical school outside the U.S. and Canada that is listed in the World Directory of Medical Schools as meeting the Educational Commission for Foreign Medical Graduates (ECFMG) eligibility requirements, and must meet all other eligibility criteria of the ECFMG. Step 3: To be eligible for Step 3, candidates must: • Have Passed Step 1 and Step 2 CK: • Successfully obtain passing scores on both Step 1 and Step 2 CK. • Hold an MD or DO Degree: • Possess an MD or DO degree from an LCME- or COCA-accredited U.S. or Canadian medical school, or an equivalent MD degree from an international medical school listed in the World Directory of Medical Schools that meets ECFMG eligibility requirements and obtain ECFMG Certification. • Meet Additional Criteria: • Fulfill all other eligibility requirements as outlined in the USMLE Bulletin of Information. The USMLE program also recommends that applicants for Step 3 have completed, or be near completion of, at least one year of postgraduate training in an accredited U.S. graduate medical education program that satisfies state board licensing requirements. == Examination components ==

Step 1 The United States Medical Licensing Examination (USMLE) Step 1 is a computer-based test that assesses whether medical students or graduates can apply important concepts of the foundational sciences fundamental to the practice of medicine. The exam consists of 280 multiple-choice questions, divided into seven 40-question blocks, and takes eight hours to complete. Step 1 is designed to test the knowledge learned during the basic science years of medical school as applied in the form of clinical vignettes. This includes anatomy, behavioral sciences, biochemistry, microbiology, pathology, pharmacology, and physiology, as well as to interdisciplinary areas including genetics, aging, immunology, nutrition, and molecular and cell biology. Epidemiology, medical ethics and questions on empathy are also emphasized. Each exam is dynamically generated for each test taker; while the general proportion of questions derived from a particular subject is the same, some test takers report that certain subjects are either emphasized or deemphasized. The USMLE Step 1 exam underwent a significant change in its scoring system in 2022, transitioning from a three-digit numeric score to a pass/fail system. Prior to this change, students received a score ranging from 1 to 300, with most scores ranging from 140 to 260. The passing score was 196, and the national mean and standard deviation were approximately 232 and 19, respectively. The scoring system used to be percentile-based, but in 1999 it was phased out in favor of the three-digit and two-digit scaled scoring system. Two-digit scores were eliminated from the score report in 2013. Step 2 Clinical Knowledge (CK) The exam is administered in a 9-hour single-day computer-based session. The session is divided into eight one-hour blocks of questions, a 15 minute tutorial and a 45 minute break. The 15-minute tutorial at the beginning of the exam is optional. The 45 minutes allowed for breaks can only be taken between sections at the discretion of the test taker. Both the unused tutorial time and time saved from finishing a test block early is added to the break time. Prior to 2020, the Step 2 exam consisted of both the CK ("Clinical Knowledge") portion, as well as a CS ("Clinical Skills") exam. However, the CS exam was put on hold in May 2020, and permanently discontinued in January 2021. Step 2 CK includes test items in the following content areas: internal medicine, obstetrics and gynecology, pediatrics, preventive medicine, psychiatry, neurology, surgery, other areas relevant to provision of care under supervision. Most Step 2 CK test items describe clinical situations and require that you provide one or more of the following: diagnosis, a prognosis, an indication of underlying mechanisms of disease, the next step in medical care, including preventive measures. As of academic year 2023-2024, the mean CK score was 249 with a standard deviation of 15 for first-time takers from accredited medical schools in the United States and Canada. The examinees should also list pertinent positive and negative findings to support each potential diagnosis. USMLE Step 3 exams are delivered online but administered only at Prometric testing centers, which emphasize identity verification and security. Examinees must provide official photo identification and fingerprints as well as pass both metal detector and physical inspection every time they wish to enter the examination room. Materials allowed within the exam room are extremely limited and most require prior approval, including medical equipment. Examinees are on video surveillance during the examination. The test is available throughout the year to the examinees. Since 2014 USMLE Step 3 can be taken on two non-consecutive days, instead of two consecutive days. • Day 2 (Advanced Clinical Medicine [ACM]) is divided into six 45-minute blocks of MCQs, and 13 computer-based case simulations (CCS). Each ACM MCQ block includes 30 items. To be eligible to take the USMLE Step 3 exam, the physician must{{cite web == Pass rates and performance ==

First-time USMLE pass rates for D.O. and M.D. students in 2020 were 91 percent and 98 percent, respectively. The first-time pass rate for students from schools outside of the United States and Canada was 90 percent. == Use in residency selection ==

The USMLE score is one of many factors considered by residency programs in selecting applicants. Many residency programs used a "cutoff" score for Step 1, below which applicants were unlikely to be considered. The NRMP Residency Program Director survey contains more information, both overall and by specialty, regarding "cutoff" scores (i.e., scores below which programs generally do not grant interviews). This, as well as the impact on student learning, cost of preparation, diversion of student time toward exam preparation, and desire to decrease racial bias, are amongst the reasons that the USMLE switched to Pass/Fail reporting of Step 1 at the beginning of 2022. The medical community has criticized the USMLE and residency programs for using Step 1 scores as the main screening tool in selecting applicants for a residency interview. Residency program directors had historically utilized the scores as a means of filtering applications down to a more manageable number that allowed for a more thorough review of the remaining ones. A significant amount of residency program directors believe that the conversion to Pass/Fail will make applicant screening more arduous. Along with the USMLE Step 1, this test is a standardized measure of all applicants. The median USMLE Step 2 scores for graduates of U.S. Medical Schools for various residencies is published periodically by the NRMP in their "Charting Outcomes in the Match" documents == Changes to Step 1 scoring ==

Transition to Pass/Fail It was announced on February 12, 2020, that beginning no earlier than January 2022, USMLE Step 1 would transition to a Pass/Fail scoring system. In July 2020, the USMLE announced that prior transcripts would not be retroactively altered." While the NBME, USMLE, and FSMB were originally against these changes (which critics argued may have been from potential monetary loss), as of 2020 (and after the formation of InCUS), they have changed their stance in support of the public opinion. Humayun Chaudhry, the President of the FSMB, (who was originally in opposition to the Step changes), later said that "although the primary purpose of the exam is to assess the knowledge and skills essential to safe patient care, the new policies will "address concerns about Step 1 scores impacting student well-being and medical education." Because students put so much emphasis on getting a high USMLE Step 1 score, they often skimmed the medical school curriculum that they deemed to be not as relevant in order to get the maximum score on the USMLE Step 1. The USMLE published a list of InCUS participants. The ECFMG and AMA supported this transition as well. Notably, medical students and program directors were among parties with only a minority in favor of this change, despite being the most directly affected. Parties associated with medical schools, namely course directors and Deans were noted to have the most support for changes. The USMLE parent organizations, including the AAFP, AMSA, and AAMC wrote letters to the USMLE recommended broad, systemic changes to the medical program including changing Step 1 to Pass/Fail. "The current overemphasis on USMLE Step 1 is having an overwhelmingly negative impact on students. This should be addressed immediately. A Pass/Fail score will help provide a more meaningful learning environment, improved emotional climate, and better student-student interactions, which can lead to better academic performance that includes USMLE tests (see Cause or effect?). Additionally, it will decrease racial bias for programs that use USMLE Step 1 scores to grant interviews." Further, they supported the move to Step 1 Pass/Fail citing unintentional negative impact of a single standardized exam on career exploration and selection. Objection to the changes Immediately following the announcement by USMLE that Step 1 would become Pass/Fail in 2022, concern has been expressed from several parties in the medical community, namely residency program directors and medical students, both among US graduates and international graduates. In a survey of nearly 300 residency program directors in surgical fields, program directors were found to significantly disagree with the statements that changing to Pass/Fail "is a good idea" (78.1% [69.9–86.4%] disagree) and the statement that "Step 2 CK should also be changed to Pass/Fail" (84.0% [76.7–91.3%]). They were also found to significantly agree with the statements that changing to Pass/Fail: "Will make it more difficult to objectively compare applicants" (88.3% [81.9–94.7%]), "Will increase emphasis on Step 2 CK scores in selecting applicants for my program" (88.7% [82.5–95.0%]), "Will make applicant screening more arduous" (85.4% [78.4–92.4%]), "I will now require applicants to submit Step 2 CK scores with ERAS" (88.4% [81.7–95.0%]), and "Where an applicant goes to medical school will be more important in screening and selection for my program" (63.5% [53.8–73.2%]). US medical students have also expressed concern that priority that would have gone to Step 1 score will instead be shifted to school prestige, student connections, clinical grading, Step 2 CK scores, and extracurricular experiences. In particular, students from DO (Doctor of Osteopathic Medicine) and "low tier" MD schools may be at considerable disadvantage compared to students from prestigious schools.{{cite web Step 2 CK is a three-digit-scored exam typically taken after the third year of medical school, which consists of clinical rotations in primary care fields. In February 2020, the Harvard Crimson wrote, "the fact that Step 2 is a more clinically relevant exam than Step 1, makes it a better proxy for clinical acumen." However, the timing of Step 2 CK is often only months before residency applications are submitted, meaning a poor score could jeopardize a student's application without allowing time to change tracks or bolster other application components. International medical students and graduates expressed growing concerns that the change will further decrease IMG (International Medical Graduates) chances of matching into US residency programs. Historically, IMGs have been at a significant disadvantage when applying to US residency programs. Outside of scores, residency program directors consider letters of recommendation, clinical grades, and research. Since international medical students come from medical schools with different grading systems and do not usually have access to well-known faculty and American research opportunities, USMLE Step 1 is often seen as a major opportunity to boost IMG residency applications with a high score. Without a numerical score on the USMLE Step 1, there is speculation that IMG's will be further be pushed out of the race for residency program spots. This was supported to some extent by General Surgery program director respondents, which significantly agreed that the changes to Pass/Fail "Will put IMGs at a disadvantage" 56.0% [48.6–63.4%]. == Controversies ==

COVID-19 response During the COVID-19 pandemic, the USMLE and NBME were met with criticism from some members of the medical community, including the American Medical Association (AMA), These experimental questions accounted for 80 of the 280 on the exam, which would have led to the decreasing the total test taking time from 7–8 hours to 5–6 hours. Some commenters expressed concerns since this practice would have "destandardized" the text and test-takers would have been "experimented" on without consent. Step 2 CS controversy The Step 2 CS exam was added to the USMLE series in 2004 by the NBME and FSMB. However, the test garnered criticism for its high exam fee and need to travel to one of five testing sites. Even before the exam was rolled out, the American Medical Association raised serious concerns with the exam, both because it failed to provide students feedback and room for remediation and because there was no proof the exam actually accomplished its mission of protecting the public. A letter to the editor from the leadership of the NBME and the FSMB in response to the article highlighted the need to view the value of the Step 2 CS in terms other than just cost; specifically, they state that:Although (the authors') interest in cost is consistent with the current climate in health care, the 'value' referenced in their title is a function of quality as well as cost. They fail to fully consider the long-term effect of this assessment program on patient safety and satisfaction, societal expectations, and effective medical education.They also note that inclusion of Step 2 CS in the USMLE "brought the USMLE closer to meeting the expectations of the public that physicians exhibit competence in communicating with and examining patients." 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 higher odds of Alpha Omega Alpha membership compared with Black, Hispanic, and other groups. In 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. $1,000 for International medical graduates (IMGs) • $660 for Step 2 CK for US/Canada students (increasing to $670 in 2024), As part of a broader public plea for systemic changes to the improper use of USMLE 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." Katsufrakis & Chaudhry Comments In December 2018, NBME President Peter Katsufrakis and FSMB President Humayun Chaudhry wrote in opposition of USMLE Step 1 changes in 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." This was met with significant backlash from students and the medical education community as this was felt to be a "tone-deaf assumption that medical trainees with more time may instead redirect their effort toward Netflix and Instagram." Within a few days, Katsufrakis and Chaudhry issued an apology and removed the phrase. ==See also==