United States Medical Licensing Examination


The United States Medical Licensing Examination is a three-step examination program for medical licensure in the United States, sponsored by the Federation of State Medical Boards and the National Board of Medical Examiners. Individuals with a Doctor of Medicine degree are required to pass the USMLE for medical licensure. Those with a Doctor of Osteopathic Medicine degree may take either the COMLEX-USA or the USMLE for medical licensure, while the COMLEX-USA is required for osteopathic licensure.
It is a standardized test that assesses a medical student's knowledge of basic science concepts and their application to clinical medicine. The exam is divided into three components required for medical licensure in the United States and is typically taken by students after their second year of medical school. States may enact additional testing and/or licensing requirements.

History

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 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. In 2004, an examination with standardized patients to assess clinical-skills was added to Step 2 of the USMLE, and required for licensure beginning with the medical school graduating class of 2005. 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.
USMLE announced a move to a pass/fail model for Step 1 on February 12, 2020, along with other changes. They claimed this was done in an attempt by the Federation of State Medical Boards and the National Board of Medical Examiners to balance focus between exams and actual coursework. The change became effective in 2022.
Before 1992, the NBME Part I examination was the primary basic science examination for medical students at the end of their second year. When the three-part United States Medical Licensing Examination was launched, the NBME Part I exam was incorporated into its new format, the USMLE Step 1 examination. Over time, the exam has evolved into a more clinically applied examination of the foundational sciences. The exam became computer-based several years later. In May 2015, the USMLE began emphasizing concepts related to patient safety and quality improvement across all parts of the USMLE exam series, including Step 1.
While traditionally, students took the USMLE Step 1 exam after completing foundational sciences and before core clinical clerkships, in the past decade, a growing number of medical schools have reformed their curricula to have students take the USMLE Step 1 after core clinical clerkships or preliminary clinical training.
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 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 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. It consists of three examinations:
  • 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 and the National Board of Medical Examiners. 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. Even though it was estimated that at least 60% of osteopathic medical students took at least one USMLE exam in 2020, physicians with D.O. degree are not required to take the USMLE for licensure or graduation. They are licensed as physicians by passing Parts I, II, and III of the COMLEX examination from the National Board of Osteopathic Medical Examiners.
As of 2024, to be eligible for the United States Medical Licensing Examination, 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:
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 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. The test is administered at the Prometric testing sites. Prior to 2020, the Step 2 exam consisted of both the CK portion, as well as a CS 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. Step 2 CK is an integrated examination that frequently requires the interpretation of tables and laboratory data, imaging studies, photographs of gross and microscopic pathologic specimens, and results of other diagnostic studies. Step 2 CK tests the aspiring physician's knowledge of medicine putting special emphasis on the principles and mechanisms underlying disease, and the therapies needed to address them.
The Step 2CK scores are reported in a 3 digit format with a range between 1 and 300. As of July 1, 2025, the passing score is 218. 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. Approximately once every four years, the USMLE decides whether to change the recommended minimum passing score. At its May 2014 meeting, the Step 2 Committee conducted a review for USMLE Step 2 Clinical Knowledge and decided to raise the Step 2 minimum passing score to 209 for students taking the test after July 1, 2014. In 2022, the passing score was increased to 214, with an implementation date of July 1, 2022. In 2025, the passing score was increased to 218, with an implementation date of July 1, 2025. USMLE provides each test taker with a score report that includes information on their performance on various physician tasks, disciplines and systems.