Ever since 1992, the FLEX exam and the NBME exams have been abolished, and in their place is the USMLE examination. The USMLE exam at this time is the sole examination used for both US and foreign medical school graduates seeking  a medical license in the US. Currently the USMLE is a computer based test that includes three parts. All three steps must be completed with in a period of 7 years in order to qualify for a state medical license.

The maximum number of times that you can take each part of the USMLE is 6 times. If you have made six prior attempts , you cannot take it any more, it is officially GAME OVER!

High Yield Notes for the USMLE

But if took any of the USMLE parts and failed it, you should consider yourself lucky, because that means you can re-take it. The worst case scenario is that you pass a part, but you pass with a low score. Now you are totally at a dead end, because if you have a low score there is no way you can get into any kind of a residency program.

The USMLE step 1 will assess your knowledge of the basic sciences. The USMLE and indeed many program directors consider this exam to be more important than even the step 2 exam. You knowledge in Microbiology, Pathology, Pharmacology, Biochemistry, Physiology and Anatomy will be thoroughly tested.

The exam consists of 7 sections of 50 questions each.

In order to apply for the USMLE step 1, it is necessary that you should have graduated from a medical school that is listed in the International Medical Directory. If you graduated from a medical school in the US or its territories or protectorates, it should be one that is accredited by the LCME.   

The step 1 exam consists of 7 sections, each one contains 50 questions.

If you have ever been dismissed from your medical school for whatever reason , you can never take the USMLE, unless you can conceal it somehow forever, which of course is an option if you trained in a med school is certain countries which we won't name here.

If your US medical school is not listed in the LCME's list, you can still take the USMLE, as long as you can get your state medical board to sponsor you.

Step 1 of the USMLE is important because residency directors use it as a measure of your overall capability, understanding and your intellectual potential. If you know your basic sciences inside out, that means you are likely to advance the frontiers of knowledge further . They would prefer to have on their team someone who shows promise for the future. Remember, unlike many other countries, America is built on innovation, and medical innovation hinges on having a solid knowledge of basic sciences. Try your best to get a top score in the USMLE.

The USMLE instituted Computer Based testing in 1999. The advantage is that the test environment is much more secure. Another advantage is that the USMLE has been able to use new methods of testing students, including audio, and video materials. The USMLE tests are currently administered at Sylvan Technology Centers all over the world. But Step 3 of the USMLE is administered exclusively in Sylvan centers in the United States. CBT is done under extreme security, the provisions include electronic fingerprinting, and audio and video monitoring of the candidates and the premises.

Recommended books for the USMLE


USMLE step 2 focuses on your patient management skills. It tests your ability to put together a working differential diagnosis, your ability to decide which tests to order, and your skill in interpreting clinical and laboratory data etc. Given a clinical scenario, it tries to gauge your ability to decide the next step.

Step 2 in effect determines whether you are safe enough to be let loose in a US hospital as a resident. It focuses mainly on Internal Medicine, but you should also have a sound knowledge of Obstetrics, Gynecology and Pediatrics. Surgery is also represented in this exam, but overall surgery is not a major player in the USMLE step 2. Another area that could trip you up is Psychiatry. You need to have a solid grounding in Psychiatry and behavioral sciences to survive the USMLE.

Keep in mind that simply being able to rattle off a list of investigations is not enough, you should be able to pick the most relevant investigation that should be done in a given clinical setting. This is highly important when you consider the new financial constraints that have befallen the US healthcare industry.


There are all kinds of prep materials available for the USMLE CS. If you are a foreign doctor, unfamiliar with the American way of Medicine, watch out! This could very well be your downfall, no matter how high your med school scores were. The American way of medicine is different from anything you have seen anywhere else. The most important part of it is what is described as 'establishing a rapport with the patient'. You have to know how to start a conversation in a friendly yet professional manner. And forget about that 'I am the almighty doctor' complex that some of you from certain parts of world may be used to when talking with patients. There is only one way to learn how to interact normally with patients, that is to hang around with a US doctor in his clinic, preferably an internal medicine clinic or family practice clinic to see how the system works. Apply for a observership at  a family practice clinic, and you will learn what to say and not to say.

The CS test lasts for 8 hours. You are not allowed to take any devices such as cellphones of a wristwatch into the testing area. If you need any assistive devices such as hearing aids , get permission in advance. Remember to take your government issued photo ID with you, either a US driving license, or any kind of passport. Your name should be exactly as it is given in the USMLE's records.

In the exam area, there will be a group of patient rooms, each one of which has a one-way mirror. The proctors will watch you during the entire thing. And outside each room will be a PC, and you will also find a clipboard, pen and paper. Also provided to you at the door will be some basic information such as vital signs (for foreign doctors not familiar with this term, it refers to BP, PR, RR and temp) and the main reason for the visit. The individuals you find in the room are actors, but handle the situation as if it was an actual patient.

You will face 12 patient encounters. You have 15 minutes for each encounter. These are common things you will see in an ordinary American family practice clinic. If you check online, you will see many IMGs whine about 'discrimination' during the course of the CS exam. This is entirely untrue. It just means that you were totally clueless , trying to do the aimless things you would do in an overseas 'clinic' as you swagger around with a stethoscope around your neck and a halo around your head and patients greet you with folded hands and bows.

If you are an IMG, there are some fundamental differences you have to understand about your healthcare system and the US healthcare system. In America, individuals have rights. You have to ask permission before you can even touch a patient, such as as "Mrs.Schmidt, would you mind if I listen to your heart sounds with my stethoscope?"  Remember to introduce yourself properly, and find out very quickly without wasting any time the reason for his or her clinic visit. You could phrase it politely as in "Mr.Hoover, What brings you to our clinic today?"  And if he says "my head is hurting, my tummy is too big and my toes are tingling", try to get things more focussed by asking, "Mr.Hoover, of all those things you mentioned, what is the one thing that bothers you the most?"

Remember to shake hands, even if it is a woman patient and you are from Afpak. You must find the chief complaint immediately. Is it headaches? Is it back pain? Once you have the chief complaint, do a quick and focussed history that includes information such as timing, frequency, severity, duration etc. Always ask for allergies, current medications, past history etc, but be careful to tailor everything to fit into the minimal amount of time available. Before you examine the patient, be sure to ask permission, "Ms.Ford, would you mind if I examine you quickly?"

Use five minutes for the history, five minutes for the physical exam, and the last five minutes to explain to the patient your impression, your differential diagnosis, and the investigations that you would like to do. Remember 'patient counseling'. If the patient has seizures, remember to advise them not to drive. These restrictions vary from state to state. If you do not know something, do not bluff, like you would do in India. Say "I am not sure, I will have to look up that information." That tells the examiner that you are genuine and honest and you are not stupid and dangerous. At the end of the interview, remember to thank the patient , say something like "It has been a pleasure meeting with you, Mr. Rowling, and thank you for allowing me to be your doctor". This is miles away from what you may be used to doing in your country, so if you want to practice medicine in the United States, you better change your way of thinking.

Another important point is, you should be able to talk English in a way that people can understand you. Attend classes with an American teacher if possible, so that you don't sound comical or incomprehensible to your American patient. If you are from China (no offence meant), this is absolutely necessary and wise.

You may be expected to type the encounter notes into the computer, so if don't know how to type on the computer, you better figure that out.


The test computer will send your answers to the National Board of Medical Examiners for scoring. The system will render your correct answers into a three digit score and a two digit score.

The mean score for US MDs is 210-230, the standard deviation being 20. On the three digit scale the passing score is 188, and on the two digit scale it is 75. A score of 99 on the two digit scale corresponds to 247 on the three digit scale.

If you are an IMG, you must score at least 220 to stand a chance. Your aim should be a score of 240 or above, which puts you in a strong position, and then you can be sure of getting interview letters.

If you have a high score, you could get an interview invitation. And if they like you, you will get matched into a program. The interview is very important. They will want to know how well you will fit into the system, and whether you can learn the ins and outs of the system quickly. If you know someone in that program who can put in a good word for you, that will go a long way.  Any research background , where you have achieved something meaningful (which excludes 99% of 'research' activities in third world countries) will help you to impress the program director. If you have any new research ideas you would like to do during the residency, that will get them excited. Be prepared to discuss study design and statistical stuff intelligently. And again, NEVER try to bluff your way through, it will never never work.

Once you get into a residency program, remember that your job is to survive. Forget about inventing a cure for cancer or the problems of the world. Learn as much as possible, take notes of everything, learn practical management skills, and be on good terms with EVERYBODY, from the CEO to the janitor. Do not make any enemies, do not get anyone mad at you.

The American medical system will impose great responsibilities on you if you manage to get into it. As a resident you have every imaginable responsibility on your shoulders, but zero authority of any kind. The key is to be tactful, smile at every dolt. No matter what happens, convince everyone how much you are enjoying three years of torture. You WILL be the whipping boy as first year resident, take it with a smile, and ask for more and they will love you. You are not going to win any Nobel prizes for medicine as a lowly resident, your first job and your second job and your third job is to survive at any cost, without getting ANYONE mad at you, not any patients, not any nurses, certainly not any attendings, and not even the janitor. If three guys badmouth you, that could shut down your career effectively.

At the interview in addition to testing your grasp of practical medicine, they will also try to find out if you are able to speak English properly and communicate properly, and also if you can get along with others. You must convince them that you are in love with whatever speciality you are are pursuing. If you have done any kind of research, and you are capable of intelligently discussing it, try to throw that into the discussion. The American scientific field is driven by innovation , while in your country probably it is driven by googling and re-inventing things that have already been invented or discovered in the US.

At this time in your life, your primary goal should be to get a USMLE score of 240. If you pass with a low score of 188, your USMLE dreams are nuked for good, never to be seen again. But if you fail the USMLE with a laughable score of 187, you are ok, because you can try again next year.

The three digit score is more important, because it remains the same regardless of the year you are tested in, whereas the two digit score is a bit tricky, its relevance changes with the year and the testing levels of other candidates. 

One important point to remember is that many program directors give more importance to the step 1 score than the step 2 score, for the simple reason that students who have a strong grounding in basic sciences are the one most likely to contribute to advances in medical science, they are considered the future of the profession.


This USMLE information section is mainly for the benefit of foreign medical graduates who are wondering what to do first to get the USMLE process started.

Here is some information about the registration process, this is primarily for the benefit of FMGs, who often do not have a clear idea as to where to start.

First and foremost, go to this website www.secure2.ecfmg.org/emain.asp?app=iwa and get your ECFMG number.
Click the link at the bottom of the page that says 'Establish an Account'. To do this, you need a working permanent email address, and you need to have a government issued (any government) photo identification. When you are filling up the online forms, make sure that your name exactly matches what is in your passport.

You will receive by email an ECFMG number (this will take about a week). Now go back to the ECFMG website and login  using your identification number and password. In case you have lost your password, call ECFG at 1-215-386-5900 to get a new password.

Once you have your ECFMG identification number and password, log into the IWA part of the ECFMG site and access the 'APPLICATION FOR ECFMG CERTIFICATION'. Once this is completed and processed, you are ready to file an application for the USMLE examination itself, follow the instructions you will receive at this point.

The USMLE examination application form includes a 'certification of identification form', which needs to be sealed and stamped by the authorized person at your medical school after you fill it out. This form must be "mailed directly" from your medical school to the ECFMG. If you are at an oversease medical school, the office there may not be inclined to entertain the ECFMG's whims and fancies, so you will need to personally go to your school office and beg or persuade them to mail out this little document, and you will probably need to hand-carry the sealed envelope to the post office and mail it yourself in case the little office clerk at your medical school is too unmotivated, as will be the case in many foreign medical schools.

Last but not the least you need an American credit or debit card or a foreign  credit or debit card that allows international transactions, and you need to have a truckload of money in your account if you are serious about pursuing this beast called the USMLE.


How many times can I attempt the USMLE?

Well it used to be that you could keep trying till your hair turns white and then some, but the USMLE rules mandate that you should finish all three exams within a seven year span of time.

If I fail, can I retake the USMLE ?

.Yes if you flunk totally you are completely fine, you can take the exam again. But if you pass with a low score you are screwed forever and then some, because you will never ever ever see the inside of a residency program, and you will probably be working as a blood draw tech instead for the rest of your days in America.

What is a passing score on the USMLE ?

On the two point system , the passing score is 75. On the three point scale the passing score is 188.

What kind of score do I need to get a good residency position?

You need something in the vicinity of 240 if you want to make sure you get a good offer from a residency program. Anything over 220 will fly.

What study materials would you recommend?

The training scene is filled with every imaginable course, each one promising you the sun and the moons and the stars. Think for yourself, avoid products that promise you miracles for minimal effort.  The USMLE takes a lot of hard work , there are no shortcuts. Pick study notes that are comprehensive, thorough and yet concise and suitable for rapid reading. We recommend the Denver Notes to help you prepare for the USMLE, these give you your best chance of getting a score that is in the 220+ range. Our other picks include the NMS series, which is something that you should read during your medical school years, and the USMLE first aid, which you should read one week before the exam.