Medical

“The Boards”: USMLE Overview

USMLE Studying

What are “The Boards”? The MCAT consumes the minds of premed students. However, an even bigger beast looms on the horizon for every allopathic medical student and would-be physician: the United States Medical Licensing Exam, often referred to as the USMLE or simply as “The Boards.” This four-part exam spans several years, includes travel and fees, and is finally completed during residency. While it represents a major source of stress for medical trainees, an understanding of the exam can help demystify the process and allow students to begin their study plans early, thus boosting confidence and reducing the associated stress.

The four parts of the USMLE exam are:

  • Step 1
  • Step 2 – Clinical Knowledge
  • Step 2 – Clinical Skills
  • Step 3

Study strategies for these exams will not be covered in detail here; however, there are many good threads on the Student Doctor Network forums that discuss various approaches to studying.

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Step 1

As its name suggests, this is the first of the USMLE series. It is generally taken after completion of the preclinical curriculum at most medical schools; some schools have started allowing students to take it after third year as well. Step 1 is a more basic sciences-focused exam. Topics covered include disease pathophysiology, anatomy and normal physiology, as well as drug pharmacology and treatments of choice. It is an eight-hour exam, in which students generally answer up to 280 multiple choice questions (MCQs) in the form of seven 60-minute, 40 question blocks. It is scored on a three digit scale, with the average score from 2017 being a 229. The exam is administered at approved standardized sites from which students can choose based on personal preference; some travel back home to study and take the exam locally, while others stay close to their medical school.

As the first installment in the long journey to medical licensure, Step 1 often becomes “the face of the USMLE.” Students find it the most stressful, high-stakes exam of the bunch for several reasons. First, this score is the most frequently-cited factor that residency program directors consider in deciding which applicants to interview for their residency, albeit among many factors (Figure 1, Results of the 2018 NRMP Program Director Survey); the pressure is on to perform well on this exam. Second, unlike the MCAT, examinees can’t retake the exam if they are unsatisfied with their score after achieving a passing grade. So medical students essentially have one shot at getting it right. Additionally, as with many things done for the first time, there is much less of an idea of what to expect going into the exam, which can cause further anxiety. To mitigate this, many students find the “Free 120” helpful. This “tutorial” of 120 USMLE questions is available for both Step 1 and Step 2 CK, and is produced by the test makers in the same format as the real thing. 

Most medical schools set aside four to six weeks without other scheduled educational activities between the completion of the preclinical curriculum and the start of third year rotations. This time is known among students simply as “Dedicated” and provides students time to prepare for this exam.

Step 2 – Clinical Knowledge

This exam is similar to Step 1 in format, albeit slightly longer, consisting of eight 60-minute blocks through a nine-hour window. Like Step 1, the blocks generally consist of around 40 questions each, with a maximum of 318 MCQs. 

Step 2 CK is most often taken after third year clerkships are complete. Its questions focus more on clinical reasoning, emphasizing diagnosis and management to a greater degree than Step 1 does (“what is the next best step in evaluation/management?” is a common catchphrase in these questions). The exam is scored on the same scale as Step 1. Because this one is taken after the experience of a year of clinical clerkships (including learning to manage real patients and studying for Step 2-style, rotation-specific Shelf exams), as well as the experience of already having passed one board exam, the average score goes up a bit (242 in 2017). Dedicated study for Step 2 CK is generally a bit shorter than its counterpart for Step 1, with students often taking two to four weeks to study.

Step 2 – Clinical Skills

CS is unique among the USMLE exams. Instead of being a multiple choice, computer-based test, this exam is administered as a series of 12 encounters with standardized patients. Actors portray someone presenting with various scenarios. The student has 15 minutes per encounter. There are announcements from overhead speakers indicating the beginning, five minute warning, and end of the 15-minute window for that encounter. During the encounters, students interview a patient to elicit the complaint and history, as well as perform relevant physical exams (some of the stations may be formatted as a phone call with a standardized patient as well). After this, students have 10 minutes to write a patient care note in the style of those used by physicians for real patient encounters; these notes are expected to include relevant findings from the history and physical exam, as well as a prioritized differential diagnosis of up to 3 conditions and the reasoning behind each. Finally, students will include the next diagnostic studies to be ordered for the patient.

Because of the unique requirements of this exam format, the test is only administered at five sites in the United States: Atlanta, Chicago, Houston, Los Angeles, and Philadelphia. In addition, it is the most expensive part of the USMLE. The $1300 testing fee is more than double the $645 fee for Step 1 and Step 2 CK, and this doesn’t include associated travel costs. Also, unlike the others, this exam is scored on a pass/fail basis.

Step 3

This is the final piece in the USMLE puzzle; it is taken during residency, usually soon after completing the first year. It is also unique from the other exams for being a two-day exam; on the first day, 232 MCQs are split into six blocks, again with 60 minutes per block (for about a seven-hour test day), similar to Step 1 and CS. However, day two is around nine hours, and consists of 180 MCQs in six blocks of 30 questions each, with 45 minutes to complete instead of 60; after this, 13 case simulations are given, with examinees having between 10-20 minutes per case. These computer-based case simulations (CCS) place the resident into the role of general primary care provider, requiring them to manage all aspects of the patient’s care, including testing, medication prescribing, consulting specialists, and managing emergencies. This is a much more free-handed way of testing what the examinee will do in a given situation, and the purpose is to assess whether the person can reasonably take care of patients unsupervised. Step 3 is scored on the same scale as Step 1 and Step 2 CK, with 226 being the average in 2017.

Once this gauntlet of exams is complete, physicians are eligible to be licensed for independent practice in their state. Although it requires significant commitment, time, money, and often stress, the first step to navigating these challenging exams is gaining a basic understanding of the process. Armed with that understanding, the next step in preparation lies in learning the content – not only to ace the exams, but more importantly, to use that knowledge to help patients.

For more information on the USMLE and its parts, visit its website.

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Harrison Snyder is a 3rd year medical student at the University of Virginia. When he’s not in the hospital or studying (which admittedly isn’t very often), he enjoys hiking, eating, playing the guitar and saxophone, animals, and following his sports teams. He is on Twitter: @MHarrisonSnyder Harrison Snyder is a 3rd year medical student at the University of Virginia. When he’s not in the hospital or studying (which admittedly isn’t ver...
"an even bigger beast looms on the horizon for every medical student and would-be physician... the USMLE"

Unless you're one of the one in four medical students attending an osteopathic school who will be required to take the COMLEX. Even if the author chooses to explain only the components of the USMLE, it seems like a large oversight to not even allude to the osteopathic equivalent.
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