What is the USMLE?
Learn what the USMLE is and why it matters for you!
Hello, World!
Part 1: Introduction to the USMLE
The journey toward becoming a licensed physician in the U.S. is demanding, and the United States Medical Licensing Examination (USMLE) serves as yet another milestone along the way. This rigorous, multi-step exam helps ensure that all aspiring physicians meet a uniform standard of medical knowledge and clinical competency. If you plan to pursue a career in medicine, then understanding the structure and significance of the USMLE is crucial.
The USMLE is a comprehensive, three-step evaluation process that assesses a prospective physician’s readiness to provide effective (and safe) patient care. Essentially, it ensures that all practicing physicians in the U.S. meet a national standard for medical knowledge and clinical skills, regardless of where they attended medical school. In this guide, we’ll break down the USMLE’s purpose and structure to help you understand what it takes to succeed and become a practicing physician in the United States.
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Part 2: Understanding the USMLE: What it is and why it matters
As mentioned above, the USMLE is a three-step examination designed to assess a future physician's ability to apply knowledge, concepts, and principles that are fundamental to effective and safe patient care. It is administered by the National Board of Medical Examiners (NBME) in collaboration with the Federation of State Medical Boards (FSMB) and is required for medical licensure in all 50 states. Essentially, you could think of the USMLE as a “gate” between you and a career as a physician. No matter how brilliant you are in the classroom, how compassionate you are with patients, or how stellar your research credentials might be, you cannot practice medicine in the United States without passing all three steps of the USMLE.
The USMLE is more than just a licensing requirement, however. It is also a significant deciding factor in residency selection. Program directors use USMLE scores as one of the primary screening tools when reviewing thousands of applications. Your performance, particularly on Step 2 CK (Clinical Knowledge), can open doors to competitive specialties or limit your options if you underperform.
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Part 3: Breakdown of the USMLE
The USMLE is divided into three sequential examinations, each designed to assess different aspects of medical knowledge and clinical competence.
Step 1: Basic Science Foundations
USMLE Step 1 assesses whether examinees understand and can apply important concepts of the basic sciences fundamental to the practice of medicine. It emphasizes principles and mechanisms underlying health, disease, and modes of therapy.
Content coverage
Step 1 consists of items designed to test basic science knowledge. Most questions in Step 1 will require examinees to “interpret graphic and tabular material, to identify gross and microscopic pathologic and normal specimens, and to solve problems through application of basic science principles.”
Specifically, the content areas covered in USMLE Step 1 include:
Human Development,
Blood & Lymphoreticular/Immune Systems,
Behavioral Health & Nervous Systems/Special Senses,
Musculoskeletal, Skin & Subcutaneous Tissue,
Cardiovascular System,
Respiratory & Renal/Urinary Systems,
Gastrointestinal System,
Reproductive & Endocrine Systems,
Multisystem Processes & Disorders,
Biostatistics & Epidemiology/Population Health, and
Social Sciences: Communication and Interpersonal Skills
The competencies that examinees must demonstrate on the USMLE Step 1 include:
Medical Knowledge: Applying Foundational Science Concepts,
Patient Care: Diagnosis,
History/Physical Examination,
Diagnosis.
Communication and Interpersonal Skills, and
Practice–based Learning & Improvement
Finally, the USMLE Step 1 tests the following discipline specifications:
Pathology,
Physiology,
Pharmacology,
Biochemistry & Nutrition,
Microbiology,
Immunology,
Gross Anatomy & Embryology,
Histology & Cell BiologyBehavioral Sciences, and
Genetics
The USMLE Step 1 has up to 280 multiple-choice questions (MCQs) and is divided into seven 60-minute blocks. Examinees take this portion of the exam in one eight-hour session.
For Step 1, questions are presented in an organ system-based format, meaning you'll see integrated questions that require you to synthesize knowledge across multiple disciplines. For example, a single question might require you to understand the biochemistry of a metabolic pathway, recognize the pathology when that pathway is disrupted, and identify the appropriate pharmacological intervention.
Medical students in the U.S. and internationally may be eligible to sit for the Step 1 exam after completing preclinical coursework. They do so typically at the end of the second year of medical school, before starting clinical clerkships. This timing makes sense because you've just completed two years of intensive basic science coursework.
Step 2: Clinical knowledge (CK)
USMLE Step 2 Clinical Knowledge (or CK) evaluates the ability to apply medical knowledge, skills, and understanding of clinical science essential for patient care under supervision. It focuses on health promotion, disease prevention, and clinical scenarios. Additionally, Step 2 is more clinically oriented than Step 1.
Content coverage
The USMLE Step 2 tests an examinee’s ability to apply medical knowledge, skills, and understanding of clinical science essential for patient care. Questions in this section will test diagnosis, prognosis, disease mechanisms, next steps in care, and preventive measures. This portion of the exam requires interpretation of tables, lab data, imaging, and clinical photographs.
In terms of specialties, the USMLE Step 2 comprises:
Internal Medicine
Surgery
Pediatrics
Obstetrics & Gynecology
Psychiatry
Preventive Medicine
Neurology
Other areas relevant to supervised patient care
The USMLE Step 2 is computer-based and consists of MCQs. It spans one nine-hour session, broken into eight 60-minute blocks (with up to 40 questions per block, for a maximum of 318 questions). The questions emphasize clinical diagnosis, management, and treatment decisions. You'll encounter scenarios that require you to determine the next best step in management, identify the most likely diagnosis, or choose the most appropriate treatment. The questions are typically longer and more clinically detailed than those in Step 1, with greater emphasis on patient presentations, physical exam findings, and diagnostic workup.
Step 3: Clinical management and decision-making
Step 3 is the final exam in the USMLE sequence. It assesses whether examinees can apply medical knowledge and an understanding of biomedical and clinical science that are essential for the unsupervised practice of medicine. The focus is on patient management, clinical decision-making, and the ability to provide care independently. It also emphasizes patient management in ambulatory settings and tests your ability to diagnose, manage, and provide ongoing care.
Specifically, the USMLE Step 3 includes the following systems:
Content coverage
Human Development,
Immune System, Blood & Lymphoreticular System, and Multisystem Processes/Disorders,
Behavioral Health,
Nervous System & Special Senses,
Skin & Subcutaneous Tissue,
Musculoskeletal System,
Cardiovascular System,
Respiratory System,
Gastrointestinal System,
Renal/Urinary & Male Reproductive Systems,
Pregnancy/Childbirth & Female Reproductive System & Breast,
Endocrine System,
Biostatistics & Epidemiology/Population Health & Interpretation of the Medical Literature, and
Social Sciences: Communication Skills/Ethics/Patient Safety
It also covers the following categories:
Immune System,
Blood & Lymphoreticular System,
Behavioral Health,
Nervous System & Special Senses,
Skin & Subcutaneous Tissue,
Musculoskeletal System,
Cardiovascular System,
Respiratory System,
Gastrointestinal System,
Renal & Urinary System,
Pregnancy, Childbirth, & the Puerperium,
Female Reproductive & Breast ,
Male Reproductive,
Endocrine System, and
Multisystem Processes & Disorders
The USMLE Step 3 also includes the following competencies:
MCQs (Day 1):
Medical Knowledge: Applying Foundational Science Concepts,
Patient Care: Diagnosis,
History/Physical Exam,
Laboratory/Diagnostic Studies,
Diagnosis,
Practice-based Learning & Improvement, and
Communication / Professionalism / Systems-based Practice & Patient Safety
MCQs (Day 2):
Patient Care: Diagnosis,
Prognosis/Outcome,
Patient Care: Management,
Health Maintenance/Disease Prevention,
Pharmacotherapy,
Clinical Interventions, and
Mixed Management
CCS (Computer-based case simulations) (Day 2):
Patient Care: Diagnosis,
History/Physical Exam,
Laboratory/Diagnostic Studies,
Diagnosis,
Prognosis/Outcome,
Patient Care: Management,
Health Maintenance/Disease Prevention,
Pharmacotherapy,
Clinical Interventions,
Mixed Management, and
Surveillance for Disease Recurrence
The USMLE Step 3 is made up of 232 MCQs for Day 1 and additional MCQs plus 13 CCSs for Day 2. This portion of the USMLE is spread over two days, each with at least seven hours of testing and breaks. The CCS component is unique to Step 3 and requires specific preparation. You'll need to become familiar with the interface and practice managing cases efficiently.
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Part 4: Scoring the USMLE
Since January 2022, the USMLE Step 1 has been reported as Pass/Fail only. Examinees must score 196 or higher to pass.
USMLE Step 2 examinees receive a three-digit numeric score and, as of July 1, 2025, must receive at least a 218 to pass.
Those taking the USMLE Step 3 receive a three-digit numeric score, plus a Pass/Fail score. Passing Step 3 of the USMLE is required for a full, unrestricted medical license in all 50 states.
Recent changes and updates
The following recent changes and updates have been made to varying parts/Steps of the USMLE:
Step 1 Step 1 is now Pass/Fail (since January 26, 2022). The decision was driven by concerns about the overemphasis on Step 1 scores in residency selection, which many felt encouraged unhealthy competition, contributed to student burnout, and didn't necessarily correlate with clinical performance or physician competence. The pass/fail system aims to reduce the stress associated with Step 1 and allow students to focus more on clinical learning rather than test preparation.
With Step 1 now pass/fail, Step 2 CK has become arguably the most important standardized metric in residency applications. This shift means you must do exceptionally well on Step 2 CK if you're aiming for competitive specialties.
Step 2 CS has been discontinued and is now pass/fail only (since January 2021).
Attempt limits: Four attempts per Step; most states require all Steps to be completed within seven years
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Part 5: Frequently asked questions about the USMLE
Who needs to take the USMLE?
All physicians seeking medical licensure in the United States, including U.S. and international medical graduates (IMGs), must pass all three steps of the USMLE.
Can I take Step 1 before finishing medical school?
You must be officially enrolled in, or a graduate of, a medical school program leading to the MD or DO degree (accredited by LCME or AOA) or an international equivalent.
What happened to Step 2 CS?
Step 2 CS was permanently discontinued in January 2021. Clinical skills are now assessed by medical schools and residency programs through alternative means.
How many times can I take each USMLE Step?
You may attempt each Step up to four times, and most state medical boards require all Steps to be completed within seven years.
When should I take each Step?
Step 1: After preclinical coursework (usually at the end of the second year)
Step 2 CK: After core clinical rotations (3rd/early 4th year)
Step 3: After medical school graduation, typically during the first year of residency
Where are the exams administered?
Step 1 and Step 2 CK are offered at Prometric centers worldwide, whereas Step 3 is only administered in the U.S. and its territories.
What is the role of USMLE in medical licensure?
Passing all three Steps is required for full, unrestricted medical licensure in the U.S.
Final thoughts
The USMLE is a cornerstone of the U.S. medical licensing process, ensuring that all practicing physicians meet rigorous national standards for knowledge and clinical skills. With recent changes—such as Step 1’s shift to pass/fail and the discontinuation of Step 2 CS—the exam continues to evolve to meet the needs of medical education and patient care. So, it’s important to be well-informed about what each Step entails, why they matter, and how each Step fits into the broader process of medical licensure.
About the Author
Dr. Shirag Shemmassianis the Founder of Shemmassian Academic Consulting and one of the world's foremost experts on medical residency admissions. For over 20 years, he and his team have helped thousands of students match to top residency programs using his exclusive approach.
