- USMLE Step 1                                                                                                                 Our Discussion Forum
- USMLE Step 2                                                                                                                 Search Our Pages
- Test of English as a Foreign Language (TOEFL)
- Clinical Skills Assessment (CSA)
- USMLE Step 3

USMLE Step 1, Step 2 and the CSA are conducted by Educational Commission for Foreign Medical Graduates (ECFMG). Step 1 and 2 can be taken in any order. The CSA can only be taken after passing step 1 and TOEFL.
USMLE Step 3 is conducted by Federation of State Medical Boards (FSMB) and can be taken only after passing Steps 1 and 2 and the CSA (must have a valid ECFMG Certificate). In some States USMLE Step 3 can be taken before starting the residency while in others it can be taken only after completing a required period of residency training, which could range from months to full course of residency. However USMLE Step 3 is not necessary for starting a residency. In order to start a residency one has to pass step 1, step 2 and CSA (have a valid ECFMG certificate).

Eligibility Reqirements for Medical Students for USMLE Steps 1 and 2
To appear in step 1 a medical student must have completed the Basic Medical Science component of medical curriculum of that medical school/college.
To appear in step 2 a medical student must be within 12 months of completion of the entire curriculum of that medical school/college.
Step 1 or 2 can be taken in any order, i.e., step 2 can be taken before step 1, but this strategy is to be strongly discouraged.

Eligibility Requirements for Medical Graduates for USMLE Steps 1 and 2
To appear in step 1 or 2 the graduates must possess their medical degree/diploma from a medical school listed in WHO directory.

Eligibility Requirements for the CSA
A medical student or graduate must have passed Step , Step 2 and TOEFL to be eligible to appear in CSA. However refer to ECFMG site for surrent inforamtion on CSA eligibilty as they are constantly changing.

Passing Scores
Minimum score to pass steps 1, 2 or 3 is frequently revised. However target should not be just to pass the step, as higher scores are needed to enter into a residency program. Maximum score in all the three steps is 99. Target should be at least a score in 90s in step 1 and high 80s in step 2. To enter a very good residency program a score in high 90s in both step 1 and 2 should be the target.
There is no scoring in CSA. One just has to pass CSA.
The minimum overall score required by ECFMG in TOEFL is 213 in the new computer-based testing (CBT) and 550 in the old paper-based testing

Examination Content of Step 1
Though called Basic Medical Science component of USMLE, the format of questions in step 1 is mainly clinical and applied. Therefore it is strongly suggested that step 1 should be taken after studying medicine and other clinical subjects if you want to obtain a high score.
Step 1 includes question in the following disciplines:
-Anatomy including gross anatomy, histology, embryology and neuroanatomy
-Physiology
-Biochemistry
-Pharmacology
-Pathology including histopathology, microbiology and immunology
-Behavioral Science
-Genetics
In addition slides from histology, histopathology, radiographs and CT scans are also included.
Majority of the questions (more than 50%) are from pathology. There are usually less than 10 questions from genetics and biochemistry, but to score high one must prepare these subjects too.

Examination Content of Step 2
Step 2 is the Clinical Science component of USMLE. Subjects covered in step 2 are:
-Internal Medicine
-Surgery
-Obstetrics and Gynecology
-Pediatrics
-Psychiatry
In addition slides from histopathology, radiographs, CT scans, and EKG are also included in the test.

Examination Content of CSA
The CSA includes cases/patients from all the major clinical disciplines including:
-Internal Medicine
-Surgery
-Obstetrics and Gynecology
-Pediatrics
-Psychiatry
Ideally CSA should be attempted after step 2.

Format of Step 1
It has 350 multiple choice questions divided into 7 blocks (50 questions per block). Each block has a maximum time limit of 60 minutes. Every question is followed by 5 or more choices/answers, of which only one is the correct choice/answer. Step 1 is a one-day exam with a total duration (including the 15 minutes tutorial at the beginning and 45 minutes of rest) of approximately 8 hours.

Format of Step 2
It has 400 multiple choice questions divided into 8 blocks (50 questions per block). Each block has a maximum time limit of 60 minutes. Every question is followed by 5 or more choices/answers, of which only one is the correct choice/answer. Step 2 is a one-day exam with a total duration (including the 15 minutes tutorial at the beginning and 45 minutes of rest) of approximately 9 hours.

Format of CSA
CSA is a test of your clinical skills of history taking and physical examination. CSA is a single day exam and each candidate has to examine 10 or 11 patients/cases. The patients are called standardized patients (SP), as they are actually healthy individuals pretending to be suffering from a particular disease. It is actually these patients who will be monitoring and scoring your skills of communication, history taking and physical examination. Moreover your skills of writing down the findings in the history and examination in the form of a Patient Note are also tested. A candidate is assessed in the following skills:

-History Taking
-Physical Examination
-Doctor-Patient interaction
-Patient counseling
-English speaking
-Writing down the findings in the form of a Patient Note.

Each patient encounter begins with a short written introduction of the patient on the door of the patient's room. Introduction includes the age, sex, reason for coming to the doctor and vital signs of the patient. Then you have 15 minutes to take a relevant history and perform a relevant physical examination on the patient. At the end of 15 minutes time, you should leave the room and write your findings on paper provided in another 10 minutes. You have to write the relevant history, important positive and negative findings on physical exmination, maximum of 5 differential diagnosis and recommend a maximum of 5 diagnostic investigations. Writing the treatment is not required. After that another patient encounter begins immediately. Rest time is provided after 4th and 8th encounter.

Recommended Books for Step 1
Click Here for a List

Recommended Books for Step 2
Click Here for a List

Recommended Books for CSA
Revise all the books recommended for step 2 above except the MCQs books and books related to imaging and EKG. In addition read the following books:
Hutchinson's Clinical Methods
Mastering the OSCE/CSA: Objective Structured Clinical Examination/Clinical Skills Assessment by Jo-Ann Reteguiz, Beverly Cornel-Avendano

Most Importantly! try to take history and examine as many patients as possible in all the clinical disciplines. Also practice speaking English as often as possible, as communication is one of the skills, which is tested in CSA.

TOEFL

You must obtain a minimum score (213 in computer-based testing and 550 in paper-based testing) set by ECFMG to be eligible to apply for CSA. However paper-based testing is no longer available in Pakistan and you must appear in computer-based TOEFL test from now on.
In order to prepare for the TOEFL you can get study material for an extra charge when you register for the test. Another highly recommended book for TOEFL is Barron's How to Prepare for the TOEFL. Also you can improve your English by speaking in English with your friends more frequently, reading an English newspaper and watching English movies.

Applying for USMLE Step 1 and 2 and CSA

You can now apply on-line for Step 1, Step 2 and CSA. Try to apply on-line if you have access to internet and have a credit card. It is very easy, fast and safe. Otherwise you can download application material from internet by visiting
www.ecfmg.org. If you have no access to the internet, you can request a free copy directly from ECFMG on the following address:

Educational Commission for Foreign Medical Graduates
3624 Market Street
Philadelphia, PA 19104-2685
USA

or you can call on (215) 375-1913 or fax to (215) 387-9963 for a free copy.

FEE

Refer to current manuals from ECFMG and TOEFL.

Appearing in TOEFL

To apply for TOEFL you can download the bulletin of information and application material from www.toefl.org or you can request the bulletin on the same site online. If you do not have access to the internet you can request the material by writing to TOEFL at your local address.


Scheduling for Steps 1, 2 and CSA

Steps 1 and 2 are conducted on daily basis. When you are applying for a step you have to indicate a 3 months eligibility period in the application form. ECFMG will send you a scheduling permit with a candidate number, which will allow you to schedule your test date during the 3 months period by calling a regional office. You can reschedule your test date any time, provided your new required date falls within the 3 months eligibility period and cancel your old schedule at least a week ahead of test date.

It is strongly advised that you should send your completed application with fee, at least 3 months before your desired test date. This is because processing of your application can take more than a month and moreover you should have sufficient time to get the test date of your choice. Ideally you should send your application by courier service like DHL or FedEx, as a postal delay can be disastrous for your planning.

CSA is conducted all year round only in Philadelphia. But before applying for CSA you should have passed step 1 and should have obtained the required score in TOEFL. Moreover you should also have submitted the TOEFL Score Acceptance Form with 40 US dollars to ECFMG. You should plan to send your application at least 4 months in advance of your desired test date, to give you sufficient time to handle the visa process.

For further information contact
Educational Comission for Foreign Medical Graduates
3624 Market Street
Philadelphia, PA 19104-2685
USA
Telephone
(215)386-5900
Fax
(215)387-9963
Website
www.ecfmg.org.
www.usmle.org.

When Should I Take USMLE ?

Usually 3 to 4 months of preparation is sufficient for both step 1 and step 2. For CSA one month of practice with the patients is enough. Try to take step 1 by the end of March or April and step 2 by the end of July. As score report usually arrives in a month so you can be able to apply for residency through ERAS by August. As the application process for residency usually starts in August so make sure that results of both steps are in your hand by this month. Although you can apply through ERAS till March but usually the interview slots are filled up by September. Thus applying late for residency will tremendously decrease your chances of getting an interview.
Also try to send your application for CSA before October. It is essential to appear in CSA by January 31st, otherwise you will loose your eligibility to remain in the Match (See Match later)
The biggest blunder most students commit is not to take TOEFL in time. As you can not apply to CSA unless you have passed TOEFL, it is utmost important that you take your TOEFL along with your step 1, ie., in March or April. This is because result of TOEFL arrives in almost 2 months and moreover you have than to send the TOEFL acceptance form to ECFMG, processing of which can take another month or so. So it takes almost 4 to 5 months from your first applying to TOEFL to its acceptance by ECFMG and only than you can be eligible to apply for CSA.
 

Applying for Residency  (Kaplan Medical's ResidencyPrep)

After you have passed USMLE, the next important step is to get apply for residency programs. Applying for residency is now much more simple and easy than before but at the same time it has become more expansive.
To apply for residency you have to register with two separate organizations. It is very important to get the application material for applying to these organizations and get registered in time.There is a fee for registration with both organizations. These two organizations are Electronic Residency Application Service (ERAS) and National Resident Matching Program (NRMP).

ERAS

ERAS is a unified system of applying to any of the residency program in the USA. First of all one should know that what is a residency program. A residency program is a specialty (like internal medicine, surgery, etc) in a specific hospital. So in one hospital there can be several residency programs. After getting registered with the ERAS, you will be given a code number by means of which you can log on to the ERAS website on the Internet. You will have to complete the application form for residency on the internet and at the same time you can select the residency programs of your choice. Thus you don't have to do any paper work. You just have to fill out your application online and ERAS will transmit your application to all the residency programs you have selected. Though there is a fee for applying to residency programs. But you have to send your Letters of Recommendations (LoRs), Dean's letter from the college principal and the Medical School Transcript to ERAS by mail. Try to obtain these documents as early as possible. Every specialty requires 3 to 4 letters of recommendations and at least one of the LoRs should be from the professor of the specialty to which you are applying.
The application form is usually available by July and try to register as early as possible (preferably in July) so that you can apply for residency in time as the processing of your application can take more than a month. You can download the application form from the ECFMG website www.ecfmg.org or you can request it from ECFMG by mail on the address provided above or by sending an email to eras-support@ecfmg.org

NRMP (MATCH)

In addition to applying to residency programs by ERAS you must also register with NRMP for the "Match". After you apply through ERAS and receive interview calls from residency programs and your interviews are over (usually the interview season last from December till February) you enter your list of hospitals (Rank Order List) in which you have been interviewed with your most preferred hospital on the top and so on. You enter your rank order list by loging into the NRMP website. Last date for entering your rank order list is usually in February. Similarly the hospitals enter their lists with the most preferred candidate on the top. In late March NRMP carries out the Match. Candidates are matched and selected for the residency programs by a computerized system.
The deadline for registering for the Match is usually December 1st, but try to register as early as possible before the deadline as you never know what might happen; your application can get lost in the mail. You can download the application form from NRMP website at www.nrmp.org and click on Independent Applicant Agreement. Or you can request the forms by email to NRMP or by mail to:

National Resident Matching Program
2501 M Street, NW Suite 1
Washington, DC 20037-1307
USA

Phone: (202) 828-0566
 

Please Refer to ECFMG, FSMB, NRMP and TOEFL for current information on policy matters.