2010 USMLE Bulletin - Examination Content

STEP 1

Step 1 includes test items in the following content areas:

• anatomy,

• behavioral sciences,

• biochemistry,

• microbiology,

• pathology,

• pharmacology,

• physiology,

• interdisciplinary topics, such as nutrition, genetics, and aging.

Step 1 is a broadly based, integrated examination. Test items commonly require you to perform one or more of the following

tasks:

• interpret graphic and tabular material,

• identify gross and microscopic pathologic and normal specimens,

• apply basic science knowledge to clinical problems.

Step 1 classifies test items along two dimensions, system and process, as shown in Table 1.

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Sample Step 1 test materials and further information on Step 1 test content are available from your registration entity and at

the USMLE website.

 Table 1: USMLE Step 1 Specifications*

System**

40%-50% General principles

50%-60% Individual organ systems

• hematopoietic/lymphoreticular

• nervous/special senses

• skin/connective tissue

• musculoskeletal

• respiratory

• cardiovascular

• gastrointestinal

• renal/urinary

• reproductive

• endocrine

Process

30%-50% Normal structure and function

30%-50% Abnormal processes

15%-25% Principles of therapeutics

10%-20% Psychosocial, cultural, occupational and environmental considerations

* Percentages are subject to change at any time. See the USMLE website for the most up-to-date information.

** The general principles category includes test items concerning those normal and abnormal processes that are not limited

to specific organ systems. Categories for individual organ systems include test items concerning those normal and abnormal

processes that are system specific.

STEP 2 CLINICAL KNOWLEDGE (CK)

Step 2 CK includes test items in the following content areas:

• internal medicine,

• obstetrics and gynecology,

• pediatrics,

• preventive medicine,

• psychiatry,

• surgery,

• other areas relevant to provision of care under supervision.

Most Step 2 CK test items describe clinical situations and require that you provide one or more of the following:

• a diagnosis,

• a prognosis,

• an indication of underlying mechanisms of disease,

• the next step in medical care, including preventive measures.

Step 2 CK is a broadly based, integrated examination. It frequently requires interpretation of tables and laboratory data,

imaging studies, photographs of gross and microscopic pathologic specimens, and results of other diagnostic studies. Step

2 CK classifies test items along two dimensions: disease category and physician task, as shown in Table 2.

Please note that much of the content that addresses normal growth and development and general principles of care is also

related to the individual organ systems categories, so that the number of questions that deal solely with normal growth and

development and general principles of care is relatively small.

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Sample Step 2 CK test materials and further information on Step 2 CK test content are available from your registration entity

and at the USMLE website.

Table 2: USMLE Step 2 CK Specifications*

Normal Conditions and Disease Categories

• Normal growth and development and general principles of care

• Individual organ systems or types of disorders

o immunologic disorders

o diseases of the blood and blood-forming organs

o mental disorders

o diseases of the nervous system and special senses

o cardiovascular disorders

o diseases of the respiratory system

o nutritional and digestive disorders

o gynecologic disorders

o renal, urinary, and male reproductive systems

o disorders of pregnancy, childbirth, and the puerperium

o disorders of the skin and subcutaneous tissue

o diseases of the musculoskeletal system and connective tissue

 o endocrine and metabolic disorders

Physician Task

15%-20% Promoting preventive medicine and health maintenance

20%-35% Understanding mechanisms of disease

25%-40% Establishing a diagnosis

15%-25% Applying principles of management

* Percentages are subject to change at any time. See the USMLE website for the most up-to-date information.

STEP 2 CLINICAL SKILLS (CS)

Step 2 CS assesses whether you can demonstrate the fundamental clinical skills essential for safe and effective patient care

under supervision. There are three subcomponents of Step 2 CS (see Table 3): Integrated Clinical Encounter (ICE),

Communication and Interpersonal Skills (CIS), and Spoken English Proficiency (SEP).

Table 3: The Subcomponents of Step 2 CS

Integrated Clinical Encounter (ICE)

• Data gathering - patient information collected by history taking and physical examination

• Documentation - completion of a patient note summarizing the findings of the patient encounter, diagnostic

impression, and initial patient work-up

Communication and Interpersonal Skills (CIS)

• Questioning skills

• Information-sharing skills

• Professional manner and rapport

Spoken English Proficiency (SEP)

 • Clarity of spoken English communication within the context of the doctor-patient encounter

Step 2 CS uses standardized patients, i.e., people trained to portray real patients. You are expected to establish rapport with

the patients, elicit pertinent historical information from them, perform focused physical examinations, answer questions, and

provide counseling when appropriate. After each interaction with a patient, you will record pertinent history and physical

examination findings, list diagnostic impressions, and outline plans for further evaluation, if necessary. The cases cover

common and important situations that a physician is likely to encounter in common medical practice in clinics, doctors’

offices, emergency departments, and hospital settings in the United States.

The cases that make up each administration of the Step 2 CS examination are based upon an examination blueprint. An

examination blueprint defines the requirements for each examination, regardless of where and when it is administered. The

sample of cases selected for each examination reflects a balance of cases that is fair and equitable across all examinees.

While the set of cases administered on a given day will differ from the set of cases administered on another day, each set of

cases is comparable.

The intent is to ensure that examinees encounter a broad spectrum of cases reflecting common and important symptoms

and diagnoses. The criteria that are used to define the blueprint and create individual examinations focus primarily on

presenting complaints and conditions. Presentation categories include, but are not limited to, cardiovascular, constitutional,

gastrointestinal, genitourinary, musculoskeletal, neurological, psychiatric, respiratory, and women's health. Examinees will

see cases from some, but not all, of these categories. The selection of cases is also guided by specifications relating to

acuity, age, gender, and type of physical findings presented in each case.

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Further information on Step 2 CS is available from your registration entity

and at the USMLE website.

STEP 3

Step 3 is organized along two principal dimensions: clinical encounter frame and physician task (see Table 4). Step 3

content reflects a data-based model of generalist medical practice in the United States.

Encounter frames capture the essential features of circumstances surrounding physicians' clinical activity with patients. They

range from encounters with patients seen for the first time for nonemergency problems, to encounters with regular patients

seen in the context of continued care, to patient encounters in (life-threatening) emergency situations. Encounters occur in

clinics, offices, skilled nursing care facilities, hospitals, emergency departments, and on the telephone. Each test item in an
encounter frame also represents one of the six physician tasks. For example, initial care encounters emphasize taking a

history and performing a physical examination. In contrast, continued care encounters emphasize decisions regarding

prognosis and management.

Table 4: USMLE Step 3 Specifications*

Clinical Encounter Frame

20%-30% Initial care

50%-60% Continued care

15%-25% Emergency care

Physician Task

8%-12% Obtaining history and performing physical examination

8%-12% Using laboratory and diagnostic studies

8%-12% Formulating most likely diagnosis

8%-12% Evaluating severity of patient's problems

8%-12% Applying scientific concepts and mechanisms of disease

45%-55% Managing the patient

• health maintenance

• clinical intervention

• clinical therapeutics

• legal and ethical issues

* Percentages are subject to change at any time. See the USMLE website for the most up-to-date information.

High-frequency, high-impact diseases also organize the content of Step 3. Clinician experts assign clinical problems related

to these diseases to individual clinical encounter frames to represent their occurrence in generalist practice.

Primum® Computer-Based Case Simulations (CCS)

Step 3 examinees test using two formats: multiple-choice questions and Primum computer-based case simulations (CCS), a

testing format that allows you to provide care for a simulated patient. You decide which diagnostic information to obtain and

how to treat and monitor the patient's progress. The computer records each step you take in caring for the patient and

scores your overall performance. This format permits assessment of clinical decision-making skills in a more realistic and

integrated manner than other available formats.

In Primum CCS, you may request information from the history and physical examination; order laboratory studies,

procedures, and consultants; and start medications and other therapies. Any of the thousands of possible entries that you

type on the "order sheet" are processed and verified by the "clerk." When you have confirmed that there is nothing further

you wish to do, you decide when to reevaluate the patient by advancing simulated time. As time passes, the patient's

condition changes based on the underlying problem and your interventions; results of tests are reported, and results of

interventions must be monitored. You suspend the movement of simulated time as you consider next steps. While you

cannot go back in time, you can change your orders to reflect your updated management plan.

The patient's chart contains, in addition to the order sheet, the reports resulting from your orders. By selecting the

appropriate chart tabs, you can review vital signs, progress notes, patient updates, and test results. You may care for and

move the patient among the office, home, emergency department, intensive care unit, and hospital ward.

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Sample Step 3 test materials and further information on Step 3 test content are available

from the FSMB and at the USMLE website.

The cases used in the CCS portion of the Step 3 examination are based upon a CCS examination blueprint. The blueprint

defines the requirements for CCS examination forms. The CCS blueprint is used to construct CCS examination forms

focusing primarily on presenting symptoms and presenting locations. Presenting symptoms relate to the Step 3

Problem/Disease List and are associated with the central nervous system, eye/ear/nose/mouth/throat, respiratory system,

circulatory system, digestive system, behavioral/emotional disorders, musculoskeletal system, skin/subcutaneous tissue,

endocrine/nutrition/metabolic disorders, kidneys/urinary tract, reproductive system, pregnancy/childbirth, neonate/childhood

illnesses, blood and blood-forming organs, infectious/parasitic diseases, injuries/wound/toxic effects/burns, and health

maintenance issues. Presenting locations include the outpatient office, emergency department, inpatient unit, intensive care

unit, and the patient's home.

You will see cases related to some, but not all, of these problem/disease and location categories. The intent is to ensure that

all examinees encounter a broad range of cases reflecting common and important symptoms and diagnoses. The selection

of cases is also guided by specifications relating to age and gender. Each CCS examination form is structured to reflect a

balance of cases that is fair and equitable for all examinees.