Every U.S. physician with an MD behind his or her name has passed the United States Medical Licensing Exam, better known as the USMLE. Actually, they’ve passed three separate USMLE exams: USMLE Step 1, Step 2 and Step 3.
The first hurdle to medical licensing that medical students cross is USMLE Step 1. This exam is taken during, or immediately after, the second year of medical school. At this point in a med student’s career they have had 4 years of undergraduate science and 2 years of medical school basic science.
A medical student taking Step 1 will be tested on physiology, anatomy, pathology, microbiology, and pharmacology. The tests expect that they understand how to recognize classic presentations of diseases and the how and why that these diseases occur, but there is very little assessment of clinical knowledge.
The reason for this in-depth basic science focus is that medical students taking USMLE Step 1 haven’t had much experience with actual patients. When a patient presents with certain symptoms the student may know that it suggests a certain diagnosis. What they don’t yet know with certainty is how to diagnose the condition. What lab tests are required? What imaging is required? What is the prognosis for this patient? What medications will best help them?
The answers to these questions come after the third year of medical school. The third and fourth years of medical school are entirely patient-based. The medical student has the amazing opportunity to essentially play doctor with real patients in hospitals and clinics. They have their own patients, take their own histories, perform physical exams, write notes and suggest assessments and diagnostic and treatment plans.
After the third year and before the midpoint of the fourth year, a medical student takes USMLE Step 2 Clinical Knowledge (Step 2 CK). Most schools also require that the student take USMLE Step 2 Clinical Skills (Step 2 CS). Step 2 CK tests the ability to read questions about patient encounters and diagnose and manage the patient’s illness. Step 2 CS, on the other hand, is performed using simulated live patients. Thus, the student has to be able to interact with patients comfortably and effectively.
The third exam, USMLE Step 3, is taken once the med student has graduated with their MD. During the first year of residency or directly after it, a doctor is required to take and pass USMLE Step 3.
These exams are intense, difficult, day-long experiences. They are expensive, require travel to specialized testing centers and are notoriously difficult. In order to pass these exams a major commitment is required. Many medical students taking the USMLE study for weeks to months as though it were a full time job.
Do these exams test what doctors really need to know? Absolutely. Steps 1 through 3 of the USMLE test everything that has been learned throughout 5 years of intensive medical training. Yes, the USMLE even test moral, cultural and social issues.
The only things important to physicians that are left out of the USMLE spectrum are things that are untestable: compassion, integrity, devotion to patient care, inner strength and resilience. These things, too, are learned in medical school, at least for those medical students who remain open and self-aware.