The USMLEs (United States Medical Licensing Examinations) are a set of medical exams designed to evaluate your readiness to safely enter the American medical system. The organisation that watches over the application of foreign nationals to the American Medical system is the ECFMG (Educational Commission for Foreign Medical Graduates) and they administer the USMLEs outside of the USA. USMLE are multiple choice exams that are now only held on computer. There are three parts, or steps, to completing the USMLE exams. The computers that you can take them are available in a large number of cities across the world on every working day of the year - you register with the ECFMG who administer the test internationally, and reserve a place at your local centre for a time when you feel ready to take the examination. Your nearest site can be found here.

The first part, USMLE step 1, is a multiple choice exam consisting of about 300 questions taken over eight hours in one day at the test center. The step 1 covers all of the basic sciences - Anatomy, Biochemistry, Physiology, statistics, Behavioural science, microbiology, pharmacology, pathology, ethics - and it is typically taken in the first half of the medical school curriculum at a time when these subjects have been covered. Scores are reported as two digit (NOT %) and three digit scores. The percentage required to pass is determined based not on a population curve, but on the relative difficulty of the items as determined by the test committee. That pass % is then set as being equal to a two digit score of 75. The mean three digit score is 200. Many programs look for two digit scores of at least 80-85 for entry. 66% of international medical graduates pass this exam with each sitting, while 91% of US medical students do. The second part was recently divided into two parts, USMLE step 2ck (clinical knowledge) and USMLE step 2cs (clinical skills). USMLE step 2 ck+cs is the examination that American medical students take before being allowed to graduate from medical school. USMLE step 2ck consists of a similar one day computer based examination, and covers all of the clinical sciences including medicine, surgery, paediatrics, obstetrics and gynaecology, psychiatry, forensics, emergency care, ENT, ophthalmology, tropical health, ethics. It is usually taken in the final year of medical school, or beyond. 75% of international medical graduates/students pass this on first sitting, while 95% of american medical students do. The USMLE Step 2cs examination is a newer requirement for ECFMG certification. The USMLE step 2cs is an expensive ($1200) examination is held in only a few American cities throughout the year. It brings examinees face-to-face with ten simulated ('standardized') patients - ie actors pretending to have specific complaints. You are tested on your ability to rapidly assess a patient, communicate your thoughts to them, and to write a note about your assessment and plans. Application is presently through the ECFMG only. As of November 2002 (when the exam was called the CSA), the pass rate was 80%, with 60% of failures being due to language difficulties. As a result of this new examination, the TOEFL will no longer be required. However the USMLE step 2cs will have an expiry date for the first time.

USMLE step 3 is taken by American students during their residency program within a year or so of graduation. International students only need to take the USMLE part 3 if they plan to immigrate on a H-1B visa (recommended over a J-1). This exam is only given in the United States, requiring you to travel here to take it. Also, only a few states (California, Connecticut, Louisiana, New York, Utah, or West Virginia) allow you to take the part 3 in their juristiction without being in an American residency program. It is largely similar in scope to the USMLE step 2 with more emphasis on practical management. The computerized test can be taken geographically in any US state at a testing center as long as you are sitting the test FOR Connecticut or New York. Application is through the state medical board. This means you can take the test in New Jersey having applied to the state medical board of Connecticut, and having passed the exam, use that result to start residency in Massachusetts.

The English Examination is not run by ECFMG any longer. If you have taken the CSA you will be required to take a TOEFL (test of english as a foreign language) examination. If you take the USMLE step 2cs, you do not have to take an additional english examination. The TOEFL is run in most countries by the Educational Testing Service. Click here for more information on the TOEFL examination.


The ECFMG Certificate

This sounds straightforward but can be unexpectedly time consuming. The ECFMG (Educational Commission for Foreign Medical Graduates) certificate is a document proving that you have fulfilled the education requirements needed to practice medicine in the USA.
The Necessary components are to have
1. - your medical degree and transcript verified by ECFMG (can take a long time)
2. - passed USMLE 1 and 2ck
3. - passed the clinical skills assessment (or step 2cs)
4. - passed a TOEFL english examination (or step 2cs)
5. - paid ECFMG in full

All of these components must be valid at the time when you apply for final certification. This certificate testifies to the fact that you have fulfilled the requirements for entry into clinical training in the USA.

Remember that the ECFMG certificate is only valid as long as its components (eg USMLE step 1) remain valid; each component has an expiry date. Your ECFMG certificate must be VALID when you apply for a visa or start your training. The english examination component expires after two years. Remember that if you have to revalidate your english test, the results of a repeat english examination will take some time to be processed to revalidate your certificate (this delayed my visa application).