Conquering the USMLE: Steps 1 and 2
Natasha Rudokova
If you’re reading this, chances are that you’re getting ready for your USMLE step 1 or step 2. This is a pretty big deal, and you should be proud of yourself for making it this far! Medical school is a big investment of time, energy, and money, and if you’re taking your USMLE, good job on getting to this point. Not everyone makes it this far, and things only get more exciting and intense from this point on! Lots of people have taken this test before you, and some of their wisdom is condensed in this article to help you understand and hopefully do outstandingly well on your USMLE steps 1 and 2.
What is the USMLE?
This really isn’t meant to insult your intelligence if you already know what the USMLE is, but a lot of people aren’t completely sure, especially before they take Step 1. Beyond being “a horrible form of torture inflicted on medical students,” the USMLE is a comprehensive series of three (technically four) exams administered to medical students. USMLE stands for United States Medical Licensing Examination, and unlike other tests like the GRE, MCAT, or LSAT, it will invade your life on multiple occasions no matter how well you do on it the first time you take it. Fortunately, knowing all about what it is and what it wants you to know can make the process a little less painful.
The USMLE is:
-A professional exam that ensures that medical students are prepared to move on in their training each year and (eventually) to receive an unrestricted medical license.
-Expensive (around $3000 in total)… unless you compare it to the cost of medical school, of course!
-Doable. You’ll be happy to know that USMLE step 1 first time pass rates range from 73% (international) to 92% (U.S.).
-Long! Each exam in the series generally lasts at least an entire day, sometimes much longer.
-Shrouded in mystery: the scores alone cause intense confusion for most people! It is very hard to find factual information about many things, including how close anyone has ever come to a “perfect score” or if achieving such a thing is even possible.
-Worthwhile. As much as medical students love to complain about the time and effort of medical school and anything relating to it, most doctors love their job and are glad they invested in their education. While it’s doubtful any of them would willingly re-take any step of the USMLE just for the fun of it, it can be another rite of passage or something to bond over with your peers!
The Basics of USMLE Step 1:
Navigating the official websites to get answers to common questions about the USMLE can be ridiculously difficult. For some reason, the people who create these websites assume people visit the website to find out why it’s theoretically important for them to take the USMLE and what experts think about the USMLE as a test. While those things are interesting (to some people), it’s not what most people are looking for! Here is some information that might be a little closer to what the average medical student is looking for:
How Much Will This Darn Exam Cost?
The USMLE step 1 itself costs $685 plus some additional fees for most people. Plan to spend $900, and whatever you don’t use to pay for the actual test can be used to pay for extra tutoring, energy drinks, or post-USMLE therapy. Don’t forget to factor in several thousand dollars for tutoring, if you plan on enlisting help from a specialized testing center like Kaplan. You should still plan on spending a good chunk of money outside the test even if you’re hiring a personal tutor, which usually costs significantly less than a center. Lastly, don’t forget about transportation and lodgings. Most people within the United States will have a testing center close to them, but some countries only have one testing location! If this location is more than an hour from your place of residence, you might consider driving there the night before and getting a hotel close to the testing center so that traffic doesn’t make you late for your exam—something that can result in you not being able to take it at all. Even if you carpool with a friend or group of fellow medical students, you should be prepared to chip in for gas.
What Do I Have to Do to Be Eligible to Take the USMLE Step 1?
The requirements of the USMLE step 1 are pretty lenient. You simply have to have completed at least two years of medical school from an institution listed in the International Medical Education Directory. You can also take step 2 before step 1 if you really want to if you meet all the requirements for step 2, even though it makes more sense for most people to take step 1 first.
What does the USMLE Step 1 actually test?
Step 1 covers a lot of basic science. More accurately, step 1 asks you about Anatomy, Physiology, Biochemistry, Pharmacology, Pathology, Microbiology, and Behavioral Sciences. In other words, you need to know enough about all of the doctor sciences to do well on the USMLE step 1. The bad news is that the USMLE step 1 is considered the hardest step in the series; the good news is that you only have to take it once if you pass.
Step 1 is made up of multiple choice questions with one right answer, and the bright side to its difficulty (for most people) is that a lot if not all questions are related to real life situations you might face as a doctor. Depending on how good your medical school is, you might have learned everything you need to know in the classroom, but that’s not the case for most people, even those who take copious notes! Using several different resources to study can be a great technique.
Online Resources
Besides the tremendous number of online study guides and programs available online, there are also tips on how to read questions properly and answer through guesswork, much like very expensive programs offered by chain companies. The chain companies and private tutors still have their value, but if you’re on an absolutely shoestring budget, you might be able to glean some of the information from your web browser.
There is also an incredibly large group of medical students just like you who are going through the same agony of the USMLE, and you can find many of them on online discussion forums like prep4usmle.com. Your search engine will probably turn up even more places for bleary-eyed pre-doctors to complain and share tips. Online forums have the benefit of archiving past conversations, so you can learn from other peoples’ triumphs and mistakes if you do a little research. Peer interaction can be a really refreshing change from tutoring or burying your face in a textbook or prep website, so an online chat room or discussion forum is a great resource, even if it’s only for stress relief! Of course, don’t forget about your real life friends, especially if they’re studying for the USMLE step 1 as well.
Where Can I take it?
You can take the USMLE step 1 at many North American and international locations. Anywhere that offers standardized tests like the MCAT or GRE is your best bet for taking the USMLE; even if they can’t let you take it there, chances are pretty good that they know where you can take it! Of course, you’ll probably be told where your nearest testing center is when you sign up online, but having an idea of where one already is can only help.
How to Succeed
The only way to do well on the USMLE step 1 is to practice and study hard. Doing that isn’t a guarantee of success, but only a handful of rare prodigies can take the USMLE without studying for it and do well! Not studying is a guaranteed failure for just about everyone.
Enlist help from a variety of sources: books, people, the internet, even videos if it helps! Companies like Kaplan offer intensive training and usually have a money back guarantee if you don’t improve your initial practice test scores, but they are very expensive. Make sure to have a variety of study materials in each medium so that you don’t have any gaps in your knowledge. Books like Laughing Your Way to Passing the USMLE are fun, but they often have a lot of information missing from them, so they shouldn’t be used as a primary resource!
Study with your friends when possible and study hard, but don’t forget to neglect any schoolwork or family obligations you might have while you’re studying. If you start studying for your USMLE step 1 a year before you plan on taking the test and you spend 30 minutes a day studying until the month before, you should make an excellent test score (assuming you’ve been studying the right materials)! Get plenty of sleep the night before and take good care of yourself while studying. Bring your USMLE study book onto the treadmill if necessary! A healthy body will tremendously help you keep a healthy and focused mind. If you have children and your spouse works, be sure to factor a babysitter into your budget, especially for the month or several before your test date. Above all else, reward yourself when you’ve finished the step 1 so you don’t dread step 2 as much.
USMLE Step 1 Scores
Most people are very curious about what a “perfect score” would be on the USMLE, and of course everyone wants to know the minimum score they can make and still pass! Since the USMLE is a multi-part test, the answer varies. For step 1, you must make a 188 (or a 75 using the two-digit scale) to pass. A perfect score is supposedly a 300, but at present it doesn’t seem like anyone has ever made it anywhere near there! If you are one of those people who frowns at receiving 99% on an exam, don’t despair if you make less than a 300 on your USMLE step 1. Remember that the person who makes a 188 and the person who makes a 270 will both (hopefully) be called the same thing eventually: doctor. Additionally, making a 300 would probably lead to a long investigation into your integrity, and you might even have to retake the exam! As long as you pass, don’t worry too intensely about your score, especially since you are not allowed to retake any step of the USMLE that you’ve already passed, except in very special circumstances. A higher score will increase your chances of getting a more competitive residency, but again, at the end of the day you should not let the scores dominate your life. The people who use USMLE step 1 scores as admissions criteria for important residencies are being big dummy-heads, according to the creators of the test (although that might be a bit paraphrased). Study hard before taking step 1, do your best, and be happy with your score if you pass— there is not much of an alternative, anyways!
If you failed your USMLE step 1, don’t be too angry with yourself either. The USMLE is a very difficult test. Get help, either online or with a real life tutor, and study your weaknesses intensely. You can retake the step 1 up to four (4) times in any 12 month period, although you have to wait 60 days after your previous attempt before taking it again. Failing it the first time (or even the first three times) might hurt your chance at getting a very competitive residency, but many established physicians remember taking the USMLE and will have compassion on someone who didn’t do amazingly well. If you had an easily explainable major life upheaval around the time of testing and you do significantly better on steps 2 and 3, you might do just fine. And again, remember that at the end of this torture, you will hopefully share the same professional title as the people who scored exceptionally well.
Once you take your test, keep in mind that it will take several weeks to get your test results (usually three or four). Don’t drive yourself insane waiting for the results! Live your life and try not to think about the results until you actually receive them. It already feels like an eternity to receive them, so don’t make it feel any longer by agonizing over it. Find something to distract yourself with; if you go back to your medical school classes immediately after taking the test, that shouldn’t be too hard!
The USMLE: Step 2
Even though this step is called “step 2,” you are not required to take this set of exams after step 1. In fact, you can take them at the same time or long before step 1, if you’re ready! However, most people take it afterwards because it asks about specific skills and knowledge that take longer to gain than the basic science understanding from early on. While you can take step 1 and step 2 in any order, you have to pass both of them (plus any additional certifications, like ECFMG) before you can take step 3 and be done with the USMLE forever.
The USMLE step 2 is actually made up of two different tests, the clinical skills section and the clinical knowledge section. The clinical knowledge section is nine hours long, and the clinical skills section isn’t much better! However, both of these tests seem to be slightly easier than step 1, and they are certainly much more similar to what you will be facing every day on the job, so take heart. Tell yourself that when these two tests are over, you will be 75% finished with the USMLE!
Clinical Knowledge Section
The clinical knowledge section of the USMLE step 2 tests you, surprisingly enough, on your clinical knowledge. The knowledge they’re looking for in this section is a lot more specific and specialized than in step 1, and each hour is broken down into one of eight categories, such as pediatrics.
Cost
The clinical knowledge test costs $780 in 2011, plus any international testing fee applied to it by a testing facility outside North America. As always, be prepared to pay way more for that for tutoring, transportation, childcare, therapy, and possibly alcohol along the way.
What Does It Test?
The USMLE step 2 clinical knowledge section is divided into 8 “blocks,” each one related to a special category. The blocks include things like internal medicine, obstetrics and gynecology, pediatrics, preventive medicine, psychiatry, surgery, or a very ominous “other” category.
The questions are much less general than in step 1, and might ask you about diagnosis, prevention, treatment, or just how the disease works. You will almost certainly have to explain lab values or imaging findings at some point during the exam. All the questions you will be asked fall into two “dimensions,” either Normal Conditions and Diseases (dimension 1) or Physician Task (dimension 2). Questions in dimension 1 are fairly generalized, and you might get a question about how the body generally works in a certain situation. Dimension 2 questions pertain to specific diseases, so a question about a rare genetic disorder might show up under that umbrella of questions.
How to Succeed
The way to succeed at the USMLE step 2 clinical knowledge exam is similar to the step 1 exam. Books, friends, classes, and the internet can all improve your scores, and you’ll need to take good care of yourself. The information is much more specialized in this section, so you’ll need to spend enough time studying each individual subject.
Like the step 1 (and most standardized tests out there, actually), the step 2 clinical knowledge portion only has single-answer multiple choice questions. These tests are often easier to figure out than fill-in-the-blank or essay style questions because the answer is presented among several others. If you rule out the answers you know are not correct, you stand a much better chance of doing well on any multiple-choice exam you’re faced with. Don’t forget that unanswered questions are penalized just as harshly as wrong answers; you’re much better off putting down your best guess than leaving the question blank!
Where Can I Take It?
You may take the USMLE Step 2 Clinical Knowledge exam in many countries around the world. It is available in virtually every country in which the step 1 exam is. Look for Prometric testing areas and chances are they will be offering the USMLE steps 1 and 2 (clinical knowledge).
What Do I Need to Score to Pass?
You must make a 189 in order to pass this section of the USMLE step 2. The average test-taker will score between 220 and 230, so if you’ve done your studying take comfort in that number! Just like with step 1, you cannot retake the test unless you fail in most circumstances, so study hard before the test and do not stress over your score afterwards. It will take several weeks to get your score, just like step 1.
The Clinical Skills Section
The clinical skills assessment used to be a test reserved exclusively for foreign medical graduates, but it has been a part of the USMLE step 2 since 2004. Some students enjoy this phase of the USMLE a lot, and others struggle and have nightmares the whole time they’re studying for it (and for months or years afterwards, in some cases). However, it can be very refreshing to switch from traditional studying methods to studying for the CSA, and it tends to measure your cumulative knowledge of medicine, so hopefully you enjoy the “break” from multiple choice drudgery that you get while practicing for and taking the clinical skills assessment.
Cost
The clinical skills section of the USMLE step 2 is pretty expensive. It costs $1,355 in 2011, but that doesn’t include the expenses for food, lodging, and travel expenses. You can only take the clinical skills section in five cities in the United States: Philadelphia, Chicago, Atlanta, Houston, and Los Angeles. You may also need to pay for tutoring to ensure that you pass this portion of the test. The clinical skills assessment is a pain in the pocket, but you can take comfort in knowing that you’re almost done with your USMLE tests after you finish the USMLE step 2!
What Does It Test?
The clinical skills section tests how well you perform in a clinical setting. Contrary to how it sounds, you will not be tested on how quickly you can draw blood or change a catheter. That’s what nurses are for, right? (In all seriousness, thank goodness for nurses who are highly skilled at those things, since most doctors fail at them!) In the clinical skills section, you will be expected to handle “patients” like a real doctor. This is basically a “field test” where you interact with a living, breathing “patient.”
How to Succeed
This guide can’t go into as much depth as necessary to teach you everything you need to learn in order to pass the clinical skills section, but it can get you started on the right path. Remember that you will be graded on your politeness and courtesy towards your patients! A lot of people don’t realize this and fail because they forgot to knock on the door, introduce themselves to the patient, or wash their hands. USMLEsource.com is a great website that will help you pass this unique step of the USMLE.
Another area that often trips up test-takers is the data collection. You have a limited amount of time with your “patient”, and you have to take good medical records in order to pass. A common acronym that people use to remember their data collection is PAM HUGS FOSS. Remember this huggy woman named Pam, and you will hopefully remember to collect:
P=past medical history
A= allergies
M= medications
H= hospitalizations
U= urological complaints
G= gastro intestinal complaints (N/V/D)
S= surgical history
F= family history
O= OB/GYN
S= sexual history
S= social history
There are many videos and practice interviews available, especially on the internet, that will show you how to act and interview during your clinical skills section. The most important thing you can do to pass your clinical skills assessment is to practice like your life depends on it! Practice on your friends, family, and most importantly, your fellow medical students. If you can find one or two medical students to practice with, you can all help catch each others’ mistakes and improve your interviewing techniques.
Where Can I take it?
You must take the USMLE Step 2 clinical skills section in the United States. There are only five testing locations, as previously mentioned, and they can be found in cities that are spread out across the United States. If you have family or friends (and free lodging) in one of those cities, you should certainly consider paying them a visit. They might be great for consolation or celebration after finishing your test. You can also travel and lodge with fellow medical students from your area or school, if they’re taking their clinical skills assessment at the same time.
What Score Do I Need to Pass?
The clinical skills portion of the USMLE is pass/fail without any numerical score. As always, you can retake your test again if you fail, and the examiners will break down the areas you did well or poorly on and explain why you failed if that’s the case.
What Now?
Once you’ve passed Step 1 and Step 2 of the USMLE, congratulations! You’re 75% done with this darned set of tests! You’re now eligible (or mostly eligible) to apply for your residencies and start “practicing” as a doctor. Most people take the USMLE step 3 after their first year of residency, so you can relax (sort of) and take some time to study in bubble baths.
Foreign Graduates
International medical school has become a very popular option recently, even among students from North America. Caribbean medical schools, for example, offer slightly more relaxed admissions standards and tuition costs than most North American schools, which has made many U.S. citizens consider them. And of course, people who are born in another country often attend medical school close to their families for social and economic reasons, even if they intend to practice in the United States eventually. Attending medical school in a country that better suits your needs and doing your residency in the United States is becomingly increasingly common, but there are a few extra steps that foreign medical graduates must complete in order to practice in the United States, even as a resident.
If you are a foreign medical graduate, you will need to take and pass the ECFMG exam before you can take your USMLE step 3 or do your residency in the United States. The ECFMG, the Educational Commission for Foreign Medical Graduates, offers the exam to ensure that medical students from countries outside the United States and Canada have learned all the factual knowledge that is taught in North American medical schools. OASIS is the online application system run by the ECFMG, and international medical students can register for their ECFMG test, check their scores, and do many other things with the system, such as import their USMLE scores.
Moving On
Once you’ve passed step 1 and step 2, you should be able to see the light at the end of the tunnel! Hopefully this guide has helped you figure out how to excel on your USMLE steps 1 and 2 and navigate some of the difficult red tape that comes with trying to complete them. Don’t forget to take good care of yourself while you’re studying your brains out for the various USMLE steps. Good luck and remember to practice, practice, practice.
