If you are a medical school student thinking about the next step in becoming a licensed physician, then you are at the right place. Thinking ahead and being aware of what lies next is essential for your medical career.

USMLE, or United States Medical License Exam, is the test that medical students have to take in the U.S. for licensure. In the U.S., you cannot legally practice medicine unless you are certified by the boards.

In this article, I will lay out the different steps of the exam, the question types, the content outline, and the time duration for each step. This will be your guide to USMLE from a beginner’s perspective so you can start preparing for the test.

What is USMLE?

United States Medical Licensing Examination or USMLE is a three-part test required for medical licensure in the United States. Students who are on their way to earn their M.D. must pass the exam to practice medicine unsupervised in the U.S. The same applies to international students who want to practice medicine in the U.S.

What are the Three Steps of USMLE?

USMLE is divided into three parts that are taken at different intervals throughout med school and then in residency. Unlike a typical standardized test like GRE or SAT, USMLE not only requires deep knowledge of the various concepts but, more importantly, your ability to apply those concepts. In other words, USMLE assesses your mastery of the material and not how good you are at taking the test.

Due to this reason, USMLE has been designed to be an extensive test that runs for 8 hours and presents hundreds of questions from different medical disciplines. The organization responsible for the test wants to ensure that a potential doctor knows all the ins and outs of their field before being trusted with human life.

Step 1 Overview

The first step of the test assesses your understanding and application of the important scientific concepts that form the basis of practical medicine. Step 1 places particular emphasis on all the principles and mechanisms responsible for illnesses, health, and modes of therapy. Moreover, a student must understand not only the foundational sciences responsible for safe medical practice in the present but also the scientific principles required for the maintenance of competence through continued learning.

Step 1: Time Duration

USMLE Step 1 is an 8-hour long test conducted in a single day. The test is divided into seven blocks, each 60-minutes long. Students are allowed a total of 45 minutes of break that they can choose to take between blocks. However, you cannot take your break during a block, and the total time of your break must not exceed 45 minutes.

Step 1: Number of questions

The first step is made up of some 280 multiple-choice questions. Each block or section contains no more than 40 questions. However, the number of questions can vary from one test to another. Since there are seven blocks, each having no more than 40 questions, the total number of questions comes out to approximately 280.

Step 1: When is it taken? 

Step 1 of USMLE is usually taken at the end of the second year of medical school.

Step 1: Question Types 

As mentioned earlier, all the questions that appear on Step 1 are Multiple choice questions. The questions are primarily designed to assess your understanding of the various medical phenomenon. Most of the questions would include a graphic or tabular material that you will have to interpret. However, there are also questions that may assess your overall knowledge of the various subjects by asking direct questions.

So what does a typical Step 1 question looks like? The following image shows a USMLE Step 1 sample question taken from an actual test:

USMLE Step 1 questions will typically include a description, known as a vignette, of a patient followed by four or more answer choices. However, you must only select the single correct answer choice and not a partially correct one.

In many instances, you will find multiple answer choices that apply to the question, but you must never forget that only one answer choice completely satisfies the question. This is part of the reason why USMLE is such a hard nut to crack.

Moreover, there is no negative marking on USMLE. Hence, even if you don’t know the correct answer, you should always take a guess. However, leaving a question will blank will automatically get you a zero. So it’s better always to guess and rely on luck than not answer at all.

Step 1: Content Outline

This is the part when you may hold your head in despair but take consolation in the fact that all aspiring doctors have to take the same test.

ALL USMLE examinations follow a specific content outline that has been decided by the boards. There are three major classifications of the content that appears in Step 1:

• Test Specifications
• Physician Tasks/Competencies
• Discipline

Below are the tables for each of these classifications. A question may include aspects from all three of the classifications. The percentages in the tables below represent weightage.

Table 1: Step 1 Test Specifications

Table 2: Physician Tasks/Competencies

Table 3: Step 1 Discipline Specifications

Note: All the percentages in each table are subject to change at any time.

Step 2 Overview

USMLE Step 2 used to have two separate components before the pandemic. However, due to covid, a step was taken to suspend the “Clinical Skills (CS)” component of step 1 in January last year. While this decision was supposed to be temporary, a recent announcement by the Federation of State Medical Boards (FSMB) has deemed the CS component permanently canceled.

So that leaves us with just the CK component, which stands for Clinical Knowledge. Step 2 CK is designed to assess a test taker’s practical application ability of medical knowledge, skills, and understanding of clinical science crucial for supervised patient care.

Step 2 CK: Time Duration 

Step 2 CK is a one-day exam that lasts for 9 hours. Examinees can take a total of a 45-minute long break in between blocks. There is also an optional 15-minute tutorial at the beginning of the test.

Step 2 CK: Number of Questions 

Step 2 CK is divided into eight 60-minute blocks. Each block contains no more than 40 questions. The total number of items/questions will not exceed 318.

Step 2: When is it taken?

Step 2 of the test is usually taken in the fourth year of medical school.

Step 2 CK: Question Type 

While all questions on USMLE Step 2 CK are MCQs, their presentation can differ. Following are the four different presentations of Step 2 CK questions, followed by an example. Note that only one answer choice is 100 percent correct for any given question.

Patient Scenario Formats

These types of questions typically provide either a vignette (plain text) or chart/tables pertaining to a patient.

Single-Item Questions

A single-item question provides a single patient-centered vignette. A specific question is asked, followed by four or more answer choices. You must select the answer choice that best answers the question. Some questions may also include pictorial or graphic materials.

Sequential Item Sets

Sequential item questions have two or three questions associated with a single patient-centered vignette. Each question will focus on a different point pertaining to the provided vignette. You must choose one answer choice per question.

Abstract Format

The abstract item format includes a summary of an experiment or clinical investigation presented in a manner commonly encountered by a physician, e.g., as an abstract that accompanies a research report in a medical journal. Examinees must interpret the abstract to answer questions on various topics, including:

• Decisions about care of an individual patient
• Biostatistics/epidemiology
• Pharmacology/therapeutics
• Use of diagnostic studies

Step 2 CK: Content Outline

Same as Step 1, Step 2 CK derives its questions from three different content classifications.

Table 1: Step 2 CK System Specifications

Table 2: Step 2 CK Physician Task/Competencies Specifications

Table 3: Step 2 CK Discipline Specifications

Note: All percentages in the tables above are subject to change at any time.

Step 3 Overview

Step 3 of the USMLE is the final step in the exam. It assesses your ability to apply medical knowledge and understand clinical and biomedical science for the unsupervised practice of medicine. Step 3 of the exam also emphasizes patient management in ambulatory settings.

Once you successfully pass this step, you are awarded a medical license to practice medicine professionally without any supervision.

Step 3: Time Duration 

USMLE Step 3 is a two-day test, unlike steps 1 and 2. The first day of the step 3 test is called  Foundations of Independent Practice (FIP). The second day of the test is known as Advanced Clinical Medicine (ACM).

Day 1: Foundations of Independent Practice (FIP)

The first component of step 3 is 7 hours long and features a total of 232 multiple-choice questions. Questions are divided into six blocks, with each block lasting 60 minutes. A 45-minute break is allowed for examinees in between blocks. Moreover, at the beginning, examinees can choose to take a 5-minute optional tutorial.

Day 2: Advanced Clinical Medicine (ACM) 

The second component of the test runs for 9 hours and includes 180 multiple-choice questions that are divided into six blocks. A block may contain up to 39 questions, and each block is 45 minutes in duration.

Unlike the first two steps, Step 3 also includes computer simulations of patient care. This part of the test is carried out on software called Primum Computer-based Case Simulations. Before the CCS, you will be asked to take a 7-minute tutorial to understand the different tools of the software.

Once the tutorial is over, you will be presented with 13 case simulations each of which can last for either 10 or 20 minutes.

Step 3: Number of Questions

Day 1 of the test has 232 multiple choice questions that are divided into six 60-minute blocks.

Day 2 of the test has 180 multiple-choice questions that are divided into six 45-minute blocks. However, the second day also constitutes 13 case simulations that can be either 10 or 20 minutes in duration.

Step 3: When is it taken?

Step 3 of the test is usually taken after the first year of residency.

Step 3: Question Types

Patient Scenario Formats

This type of question provides a vignette or a chart or table relating to a patient’s medical history. You will be asked to choose the best answer choice depending on the information given in the question.

Single-Item Questions

A single-item question provides a single patient-centered vignette. A specific question is asked, followed by four or more answer choices. You must select the answer choice that best answers the question. Some questions may also include pictorial or graphic materials.

Multiple Item Sets

This type of question is based on a single vignette. However, the number of sub-questions can vary from 2-3, but they are all independent of each other. Therefore, you have to select one answer choice for each question that best answers the said question.

Sequential Item Sets

Sequential item questions have two or three questions associated with a single patient-centered vignette. Each question will focus on a different point pertaining to the provided vignette. You must choose one answer choice per question.

Pharmaceutical Advertisement (Drug Ad) Format

This question type provides a drug advertisement commonly found in medical journals. Examinees are rewuired to interpret the information and then answer the question. The questions can pertain to different topics such as:

• Decisions about care of an individual patient
• Biostatistics/epidemiology
• Pharmacology/therapeutics
• Development and approval of drugs and dietary supplements
• Medical ethics

Abstract Format 

An abstract format question includes a brief summary of a clinical experiment or investigation. The summary is typically written in a format that is found in medical journals, such as abstracts of a research study. Examinees are required to interpret the abstract and answer the questions on topics such as:

• Decisions about care of an individual patient
• Biostatistics/epidemiology
• Pharmacology/therapeutics
• Use of diagnostic studies

Primum Computer-based Case Simulations (CCS)

You will be required to analyse 13 computer case simulations through software called Primum. You will be able to interact with the patient using various tools and buttons. Moreover, The software will also allow you to access a patient’s past medical history.

At the beginning of each case, you will see the clinical setting, simulated case time, and introductory patient information. Photographs and sounds will not be provided.

Normal or reference laboratory values will be provided with each report; some tests will be accompanied by a clinical interpretation. To manage patients using the Primum CCS software, you must complete the Primum tutorial and sample casesprovided. A brief description of the interface is provided in the Primum Tutorial.

Step 3: Content Outline

Table 1: MCQ Test Content Specifications

Table 2: CCS Test Content Specifications

Note: Categories in bold are covered in CCS cases; categories not in bold are not covered.

Table 3: MCQ Physician Tasks Competencies Specifications

Table 4: CCS Physician Tasks/Competencies Specifications

Note: Categories in bold are covered in CCS cases; categories not in bold are not covered.