Friday, January 31, 2014

Step 2 CK

 USMLE Step2 CK Exam


 

 

 

Step 2 CK Overview

The Step 2 Clinical Knowledge (Step 2 CK) portion of the Step 2 exam consists of multiple-choice questions that reflect the broad representation of academics, clinical practice, and licensing communities across the United States and Canada. The clinical science material of the Step 2 CK is organized along two dimensions:
  • Normal conditions and diseases (normal growth and development, basic concepts, and general principles) and
  • Physician tasks (preventive medicine and health maintenance, understanding mechanisms of disease, establishing a diagnosis, and patient management).

Examination Content

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.
Normal Conditions and Disease Categories
  • Normal growth and development and general principles of care
  • Individual organ systems or types of disorders
    • Immunologic disorders
    • Diseases of the blood and blood-forming organs
    • Mental disorders
    • Diseases of the nervous system and special senses
    • Cardiovascular disorders
    • Diseases of the respiratory system
    • Nutritional and digestive disorders
    • Gynecologic disorders
    • Renal, urinary, and male reproductive systems
    • Disorders of pregnancy, childbirth, and the puerperium
    • Disorders of the skin and subcutaneous tissue
    • Diseases of the musculoskeletal system and connective tissue
    • 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.

Test Length and Format

Step 2 CK has maximum of 355 multiple-choice test items. It is divided into eight sixty minute blocks and administered in one nine hour testing session. For Step 2 CK, during the defined time to complete the items in each block, you may answer the items in any order, review your responses, and change answers. After you exit the block or when time expires, you can no longer review test items or change answers.

Eligibility Criteria

To be eligible for Step 2 CK, you must be in one of the following categories at the time of application and on the test day:
  • a medical student officially enrolled in, or a graduate of, a US or Canadian medical school;
  • program leading to the MD degree that is accredited by the Liaison Committee on Medical Education (LCME);
  • a medical student officially enrolled in, or a graduate of, a US medical school leading to the DO degree that is accredited by the American Osteopathic Association (AOA); or
  • a medical student officially enrolled in, or a graduate of, a medical school outside the United States and Canada and eligible for examination by the ECFMG.
Disclaimer The information presented on this page is taken from the official USMLE website www.usmle.org.Please refer to the official USMLE website for more information on Applying for the Test, Scheduling Your Test Date and up-to-date test information.

USMLE Step 1 Exam Facts

USMLE Step 1 Exam Facts

When should I take Step 1?

Most medical students take the USMLE Step 1 test after finishing their basic science classes and before starting the clinical clerkships, usually in the summer between the second and third years at most programs. Many institutions offer a 1-2 month break during this time for students to study and take the test, with some students deciding to take it earlier and have a longer break whereas others use as much time as possible for studying. This decision may have a large impact, given the heavy emphasis placed on the test results by program directors.
A 2002 study looked at student scores based on the timing of when they took the USMLE Step 1. Students who took the exam earlier tended to have a better academic record based on preclinical grades and MCAT scores. Many students who took the exam later did so because of personal issues or a need for remediation after second year classes. As might be expected, the pass rate among students who took the exam earlier was higher than it was among those who took it later, but this is confounded by the difference in academic record between these two groups. When performance was adjusted based on these variables there was no significant difference in scores related to when the exam was taken.
One can approach this data in several ways. Decreased retention of material with longer delays after finishing the basic science classes is unlikely to be much of a factor as there is a relatively short interval between when most students finish basic science classes and take the exam anyway. This is in contrast to Step 2 where there is often a longer interval between when students finish clinical clerkships and take the exam, a factor which has been correlated with performance on the test . In addition, students who fear they will do poorly on the test and take extra time to study may not do any better on the test than if they had taken it earlier.

Reference

How much basic science material from USMLE Step 1 will I end up remembering in the long term?

The retention and relevance of basic science material learned during medical school has long been a concern. This is part of the reason there has been a shift in medical education towards including more clinically relevant material during the first two years of medical school. There has also been a shift towards more patient cases being included in USMLE Step 1; previously only 30% of cases used a patient-based format, whereas now roughly 70% of cases do.
A 2008 study examined the results of including unscored Step 1 questions on the Step 2 CK exam. Students answering the questions as a component of the Step 2 CK exam, i.e. later in their medical training, performed approximately 6-7% poorer than students answering the questions as a component of the Step 1 exam. This decline was greater for questions that were presented in a style other than a patient vignette. The question category with the largest drop in performance was biochemistry, followed by microbiology and pharmacology. The drops were less dramatic for physiology, anatomy, and pathology. Performance actually increased for human behavior related questions. Changes in performance likely reflect emphasis placed during clinical clerkships, where biochemical principles are rarely discussed but aspects of human behavior such as communication and mental disorders are frequently discussed.
Similar studies have been conducted over the past three decades. Interestingly, the results of the most recent study were similar to those of earlier studies despite the changes made to medical education. In fact, the magnitude of decline was actually worse on the more recent study than those from years prior to changes in medical school curricula. Some of this may be secondary to fourth year medical students taking Step 2 later in the year, therefore increasing the interval since Step 1 and decreasing retention of the material.

Reference

How much is my performance on the USMLE exams affected by the medical school I attend?

A variety of factors go into a student's choice of medical school. Schools vary in geographic location, curriculum, teaching quality, and reputation. It is difficult to compare medical schools in overall quality, except in the form of published rankings, which are of questionable validity. It is also unclear if differences between medical schools significantly impact a student's eventual performance in clinical situations or on standardized tests.
A 2008 study compared USMLE scores across multiple medical schools. Overall USMLE scores did vary among institutions, as would be expected. However, the majority of these differences could be accounted for by differences in incoming students, particularly MCAT scores. In other words, schools admitting students who are better test-takers tended to have higher average USMLE scores. Approximately 85% of the variation between schools can be traced to this variation among incoming students.
Only about 15% of the variation in USMLE score across different medical schools could be traced to factors related to the school itself. Little of this difference could be traced to differences in curriculum or school level-educational policies. Private school students tended to perform better on Step 1 but worse on Step 3. The geographic location of the school also impacted scores. This study did not directly address the quality of teaching that students receive, in part because this is difficult to assess and quantify. Overall these findings suggest that the majority of variation in USMLE performance among different schools is likely secondary to traits that the students bring into the medical school environment, rather than differences between medical schools themselves.

Reference

Are my MCAT scores predictive of my USMLE and medical school performance?

Much as the USMLE Step 1 score is an important variable in the residency application process, the MCAT score is given important weight in the medical school application process. Medical school admissions officers are faced with the daunting task of determining which students are the most qualified, comparing applicants from different institutions of different quality and grading schemes. The MCAT is meant as an objective and consistent means of comparison, though other factors are certainly considered in the medical school application process.
A 2007 meta-analysis evaluated the relationship between the MCAT and medical school performance. There was a small to moderate correlation of MCAT performance with performance during the preclinical years, with the r value equal to roughly 0.39. There was also a correlation of certain subtests with preclinical performance, particularly the biological sciences subtest. The correlation was less strong between MCAT performance and performance during the clinical years. The writing subtest of the MCAT was shown to have no correlation with either performance during the preclinical years or the clinical clerkships.
A small to moderate correlation was also found between MCAT and USMLE scores, with r values ranging from 0.38 to 0.60. This correlation was highest for USMLE Step 1. Among the different MCAT subsets, the highest correlation was found for the biological sciences and verbal sections. There was near zero correlation between the writing subtest and USMLE scores.

Reference

Are my USMLE scores affected by whether my medical school has a problem-based or traditional curriculum during the basic science years?

Over the past several decades, many medical schools have changed their curriculum from a more traditional format to problem-based learning (PBL). Studies have shown that graduates of PBL curriculums tend to have better clinical performance during residency, though not to a statistically significant degree. Students also generally prefer the PBL curriculum when given the choice. However, some worry the PBL approach may compromise basic science education, potentially hindering performance on USMLE exams, particularly Step 1. Multiple studies have examined this concern and the results have been mixed. The majority of these studies have demonstrated no significant difference in test performance between students on the two tracks. Exceptions include one study of students at the University of New Mexico which demonstrated a statistically significant increase in Step 1 scores among students taking a traditional curriculum and a trend towards improved Step 2 performance in students taught with a PBL curriculum. A study of University of Missouri students demonstrated improved performance on Steps 1 and II with a PBL curriculum. Students at Wake Forest University and Michigan State University showed similar test performance regardless of teaching style. While these studies do not draw any hard and fast conclusions, they suggest that the two tracks are roughly equivalent in terms of how they prepare students for the USMLE. A potential confounder in these studies is that students with less basic science background entering medical school may favor programs offering a PBL-style curriculum, as decreased basic science background is an independent predictor of poorer USMLE performance.

Reference

Thursday, January 30, 2014

STEP 1 OVERVIEW

USMLE Step 1 Exam

 


Step 1 Overview

The Step 1 examination is the first component of the USMLE and is taken by medical students and graduates seeking to practice medicine in the United States. The overall purpose of the Step 1 exam is to assess an individual’s basic science knowledge. The content that comprises this multiple choice exam is organized into general science principles and individual organ systems. While some of the exam questions may involve testing an examinee’s range of knowledge, most of the questions place a strong emphasis on the application of basic science principles in the practice of clinical medicine.

Introduction


Step 1 consists of multiple-choice questions prepared by examination committees composed of faculty members, teachers, investigators, and clinicians with recognized prominence in their respective fields. Committee members are selected to provide broad representation from the academic, practice, and licensing communities across the United States and Canada. The test is designed to measure basic science knowledge. Some questions test the examinee's fund of information per se, but the majority of questions require the examinee to interpret graphic and tabular material, to identify gross and microscopic pathologic and normal specimens, and to solve problems through application of basic science principles.
Step 1 is constructed from an integrated content outline that organizes basic science content according to general principles and individual organ systems. Test questions are classified in one of these major areas depending on whether they focus on concepts and principles that are important across organ systems or within individual organ systems.
Sections focusing on individual organ systems are subdivided according to normal and abnormal processes, principles of therapy, and psychosocial, cultural, and environmental considerations. Each examination covers content related to the traditionally defined disciplines of anatomy, behavioral sciences, biochemistry, microbiology, pathology, pharmacology, and physiology, as well as to interdisciplinary areas including genetics, aging, immunology, nutrition, and molecular and cell biology. While not all topics listed in the content outline are included in every examination, overall content coverage is comparable in the various examination forms that will be taken by different examinees.
The Step 1 content outline describes the scope of the examination in detail but is not intended as a curriculum development or study guide. It provides a flexible structure for test construction that can readily accommodate new topics, emerging content domains, and shifts in emphasis. The categorizations and content coverage are subject to change. Broadly based learning that establishes a strong general understanding of concepts and principles in the basic sciences is the best preparation for the examination.

Examination Content

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 below:

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

        
 Disclaimer Percentages are subject to change at any time. See the USMLE website for the most up-to-date         information.
 Disclaimer The general principles category includes test items concerning those normal and abnormal processes that are not limited to specific organ systems. 
 Disclaimer Categories for individual organ systems include test items concerning those normal and abnormal processes that are system-specific.

 Content Outlines

 General Principle
  1. Biochemistry and molecular biology
    • gene expression: DNA structure, replication, exchange, and epigenetics
    • gene expression: transcription
    • gene expression: translation, post-translational processing, modifications, and disposition of proteins (degradation), including protein/glycoprotein synthesis, intra/extracellular sorting, and processes/functions related to Golgi complex and rough endoplasmic reticulum
    • structure and function of proteins and enzymes
    • energy metabolism
    Biology of cells
    • adaptive cell responses and cellular homeostasis
    • intracellular accumulations
    • mechanisms of injury and necrosis
    • apoptosis
    • mechanisms of dysregulation
      • cell biology of cancer, including genetics of cancer
      • general principles of invasion and metastasis, including cancer staging
    • cell/tissue structure, regulation, and function, including cytoskeleton, organelles, glycolipids, channels, gap junctions, extracellular matrix, and receptors
    Human development and genetics
    • principles of pedigree analysis
      • inheritance patterns
      • occurrence and recurrence risk determination
    • population genetics: Hardy-Weinberg law, founder effects, mutation-selection equilibrium
    • principles of gene therapy
    • genetic testing and counseling
    • genetic mechanisms
    Biology of tissue response to disease
    • acute inflammatory responses (patterns of response)
      • acute inflammation and mediator systems
      • vascular response to injury, including mediators
      • principles of cell adherence and migration
      • microbicidal mechanisms and tissue injury
      • clinical manifestations
    • chronic inflammatory responses
    • reparative processes
      • wound healing, hemostasis, and repair; thrombosis, granulation tissue, angiogenesis, fibrosis, scar/keloid formation
      • regenerative processes
    Gender, ethnic, and behavioral considerations affecting disease treatment and prevention, including psychosocial, cultural, occupational, and environmental
    • progression through the life cycle, including birth through senescence
      • cognitive, language, motor skills, and social and interpersonal development
      • sexual development
      • influence of developmental stage on physician-patient interview
    • psychological and social factors influencing patient behavior
      • personality traits or coping style, including coping mechanisms
      • psychodynamic and behavioral factors, related past experience
      • family and cultural factors, including socioeconomic status, ethnicity, and gender
      • adaptive behavioral responses to stress and illness
      • maladaptive behavioral responses to stress and illness
      • interactions between the patient and the physician or the health care system
      • patient adherence (general and adolescent)
    • patient interviewing, consultation, and interactions with the family
      • establishing and maintaining rapport
      • data gathering
      • approaches to patient education
      • enticing patients to make lifestyle changes
      • communicating bad news
      • "difficult" interviews
      • multicultural ethnic characteristics
    • medical ethics, jurisprudence, and professional behavior
      • consent and informed consent to treatment
      • physician-patient relationships
      • death and dying
      • birth-related issues
      • issues related to patient participation in research
      • interactions with other health professionals, including impaired physician and patient safety
      • sexuality and the profession; other "boundary" issues
      • ethics of managed care
      • organization and cost of health care delivery
    Multisystem processes
    • nutrition
      • generation, expenditure, and storage of energy at the whole-body level
      • assessment of nutritional status across the life span, including calories, protein, essential nutrients, hypoalimentation
      • functions of nutrients
      • protein-calorie malnutrition
      • vitamin deficiencies and/or toxicities (including megaloblastic anemia with other findings)
      • mineral deficiencies and toxicities
    • temperature regulation
    • adaptation to environmental extremes, including occupational exposures
      • physical and associated disorders (including temperature, radiation, burns, decreased atmospheric pressure, high-altitude sickness, increased water pressure)
      • chemical (including gases, vapors, smoke inhalation, agricultural hazards, organic solvents, heavy metals, principles of poisoning and therapy)
    • fluid, electrolyte, and acid-base balance disorders
    • inherited metabolic disorders, including disorders related to amino acids, purines, porphyrins, carnitine, fatty acids, and carbohydrates
    Pharmacodynamic and pharmacokinetic processes
    • general principles
      • pharmacokinetics: absorption, distribution, metabolism, excretion, dosage intervals
      • mechanisms of drug action, structure-activity relationships (including anticancer drugs)
      • concentration- and dose-effect relationships, types of agonists and antagonists and their actions
      • individual factors altering pharmacokinetics and pharmacodynamics
      • mechanisms of drug adverse effects, overdosage, toxicology
      • mechanisms of drug interactions
      • regulatory issues
      • signal transduction, including structure/function of all components of signal transduction pathway such as receptors, ligands
      • cell cycle/cell cycle regulation
    Microbial biology and infection
    • microbial identification and classification, including principles, microorganism identification, and nonimmunologic lab diagnosis
    • bacteria
      • structure
      • processes, replication, and genetics
      • oncogenesis
      • antibacterial agents
    • viruses
      • structure
      • processes, replication, and genetics
      • oncogenesis
      • antiviral agents
    • fungi
      • structure
      • processes, replication, and genetics
      • antifungal agents
    • parasites
      • structure
      • processes, replication, and genetics
      • antiparasitic agents
    • prions
    • epidemiology, outbreaks, and infection control
    Quantitative methods
    • fundamental concepts of measurement
      • scales of measurement
      • distribution, central tendency, variability, probability
      • disease prevalence and incidence
      • disease outcomes
      • associations
      • health impact
      • sensitivity, specificity, predictive values
    • fundamental concepts of study design
      • types of experimental studies
      • types of observational studies
      • sampling and sample size
      • subject selection and exposure allocation
      • outcome assessment
      • internal and external validity
    • fundamental concepts of hypothesis testing and statistical inference
      • confidence intervals
      • statistical significance and Type I error
      • statistical power and Type II error

  2. Hematopoietic and Lymphoreticular Systems
    Normal processes
    • embryonic development, fetal maturation, and perinatal changes
    • organ structure and function
    • cell/tissue structure and function
      • production and function of erythrocytes, hemoglobin, O2 and CO2 transport, transport proteins
      • production and function of platelets
      • production and function of coagulation and fibrinolytic factors
    • repair, regeneration, and changes associated with stage of life
    Abnormal processes
    • infectious, inflammatory, and immunologic disorders
      • infections of the blood, reticuloendothelial system, and endothelial cells
      • autoimmunity and autoimmune diseases
      • anemia of chronic disease
      • non-immunologically mediated transfusion complications, transplant rejection
    • traumatic and mechanical injury
    • neoplastic disorders (including lymphoma, leukemia, multiple myeloma, dysproteinemias, amyloidosis)
    • metabolic and regulatory disorders, including acquired
      • nutritional anemias
      • cythemia
      • hemorrhagic and hemostatic disorders
      • bleeding secondary to platelet disorders and disorders of primary hemostasis
    • vascular and endothelial disorders
    • systemic disorders affecting the hematopoietic and lymphoreticular system
    • idiopathic disorders
    • degenerative disorders
    • drug-induced adverse effects on the hematopoietic and lymphoreticular systems
    • congenital and genetic disorders affecting the hematopoietic and lymphoreticular systems
    Principles of therapeutics
    • mechanisms of action and use of drugs for treatment of disorders of the hematopoietic system
      • blood and blood products
      • treatment of anemia, drugs stimulating erythrocyte production
      • drugs stimulating leukocyte production
      • anticoagulants, thrombolytic drugs
      • antiplatelet drugs
      • antimicrobials and antiparasitics
      • antineoplastic and immunosuppressive drugs in the clinical context of disease
    • other therapeutic modalities
    Gender, ethnic, and behavioral considerations affecting disease treatment and prevention, including psychosocial, cultural, occupational, and environmental
    • emotional and behavioral factors
    • influence on person, family, and society
    • occupational and other environmental risk factors
    • gender and ethnic factors

  3. Central and Peripheral Nervous Systems
    Normal processes
    • embryonic development, fetal maturation, and perinatal changes, including neural tube derivatives, cerebral ventricles, neural crest derivatives
    • organ structure and function
      • spinal cord, including gross anatomy, blood supply, and spinal reflexes
      • brain stem
      • brain, including gross anatomy and blood supply; cognition, language, memory; hypothalamic function; limbic system and emotional behavior; circadian rhythms and sleep; control of eye movement
      • sensory systems, including proprioception, pain, vision, hearing, balance, taste, and olfaction
      • motor systems, including brain and spinal cord, basal ganglia, and cerebellum
      • autonomic nervous system
      • peripheral nerve
    • cell/tissue structure and function
      • axonal transport
      • excitable properties of neurons, axons and dendrites, including channels
      • synthesis, storage, release, reuptake, and degradation of neurotransmitters and neuromodulators
      • pre- and postsynaptic receptor interactions, trophic and growth factors
      • brain metabolism
      • glia, myelin
      • brain homeostasis: blood-brain barrier; cerebrospinal fluid formation and flow; choroid plexus
    • repair, regeneration, and changes associated with stage of life, including definition of brain death
    Abnormal processes
    • infectious, inflammatory, and immunologic disorders (including demyelinating disorders, myasthenia gravis and muscle channelopathies, and disorders of the eye and ear)
    • traumatic and mechanical disorders
    • neoplastic disorders, including primary and metastatic
    • metabolic and regulatory disorders
    • vascular disorders
    • systemic disorders affecting the nervous system
    • idiopathic disorders affecting the nervous system
    • congenital and genetic disorders, including metabolic
    • degenerative disorders
    • paroxysmal disorders
    • disorders of special senses
    • psychopathologic disorders, processes, and their evaluation
      • early-onset disorders
      • disorders related to substance use
      • schizophrenia and other psychotic disorders
      • mood disorders
      • anxiety disorders
      • somatoform disorders
      • personality disorders
      • physical and sexual abuse of children, adults, and elders
      • other disorders
    • drug-induced adverse effects on the central and peripheral nervous system
    • neurologic pain syndromes
    Principles of therapeutics
    • mechanisms of action and use of drugs for treatment of disorders of the nervous system
      • anesthetics
      • hypnotic sedatives
      • psychopharmacologic agents
      • anticonvulsants
      • analgesics
      • stimulants, amphetamines
      • antiparkinsonian drugs and drugs for dementia, Alzheimer type; multiple sclerosis; and restless legs syndrome
      • skeletal muscle relaxants, botulinum toxin
      • neuromuscular junction agonists and antagonists
      • antiglaucoma drugs
      • drugs used to decrease intracranial pressure
      • antimigraine agents
      • drugs affecting the autonomic nervous system, including all general autonomic pharmacology
      • antimicrobials, antineoplastic drugs, and antiparasitics
      • drugs used to treat cerebrovascular disorders
      • treatment for substance abuse disorders
    • other therapeutic modalities
    Gender, ethnic, and behavioral considerations affecting disease treatment and prevention, including psychosocial, cultural, occupational, and environmental
    • emotional and behavioral factors
    • influence on person, family, and society
    • occupational and other environmental risk factors
    • gender and ethnic factors

  4. Skin and Related Connective Tissue
    Normal processes
    • embryonic development, fetal maturation, and perinatal changes
    • organ structure and function
    • cell/tissue structure and function, including barrier functions, thermal regulation, eccrine function
    • repair, regeneration, and changes associated with stage of life or ethnicity
    • skin defense mechanisms and normal flora
    Abnormal processes
    • infectious, inflammatory, and immunologic disorders
      • bacterial infections
      • viral infections
      • fungal infections, including mycoses, dermatophytosis
      • parasitic infections, ectoparasitic infestations, and mycobacterial infections
      • immune and autoimmune disorders
    • traumatic and mechanical disorders (including thermal injury, decubitus ulcers, effects of ultraviolet light and radiation)
    • neoplastic disorders
      • keratinocytes
      • melanocytes
      • vascular neoplasms
      • other
    • metabolic, regulatory, and structural disorders
    • vascular disorders
    • systemic disorders affecting the skin
    • idiopathic disorders
    • degenerative disorders
    • drug-induced adverse effects on the skin and related connective tissue
    • congenital and genetic disorders affecting the skin and related connective tissue
    Principles of therapeutics
    • mechanisms of action and use of drugs for treatment of disorders of the skin and connective tissue
      • anti-inflammatory agents
      • emollients
      • sunscreen
      • retinoids
      • antimicrobial and antiparasitic agents
      • cytotoxic and immunologic therapy and antineoplastic drugs
    • other therapeutic modalities
    Gender, ethnic, and behavioral considerations affecting disease treatment and prevention, including psychosocial, cultural, occupational, and environmental
    • emotional and behavioral factors
    • influence on person, family, and society
    • occupational and other environmental risk factors
    • gender and ethnic factors

  5. Musculoskeletal System
    Normal processes
    • embryonic development, fetal maturation, and perinatal changes
    • organ structure and function
    • cell/tissue structure and function
      • biology of bones, joints, tendons, skeletal muscle
      • exercise and physical conditioning
    • repair, regeneration, and changes associated with stage of life
    Abnormal processes
    • infectious, inflammatory, and immunologic disorders
    • traumatic and mechanical disorders (including fractures, sprains, strains, dislocations, joint injuries, repetitive motion injuries, and impingement syndrome)
    • neoplastic disorders
    • metabolic, regulatory, and structural disorders (including osteomalacia, osteoporosis, osteodystrophy, gout, and pseudogout)
    • vascular disorders
    • systemic disorders affecting the musculoskeletal system
    • idiopathic disorders
    • degenerative disorders
    • drug-induced adverse effects on the musculoskeletal system
    • congenital and genetic disorders affecting the musculoskeletal system
    Principles of therapeutics
    • mechanisms of action and use of drugs for treatment of disorders of the musculoskeletal system
      • nonsteroidal anti-inflammatory drugs and analgesics
      • muscle relaxants
      • antigout therapy
      • immunosuppressive and antineoplastic drugs
      • drugs affecting bone mineralization
      • antimicrobial and antiparasitic agents
    • other therapeutic modalities
    Gender, ethnic, and behavioral considerations affecting disease treatment and prevention, including psychosocial, cultural, occupational, and environmental
    • emotional and behavioral factors
    • influence on person, family, and society
    • occupational and other environmental risk factors
    • gender and ethnic factors

  6. Respiratory System
    Normal processes
    • embryonic development, fetal maturation, and perinatal changes
    • organ structure and function
      • airways, including mechanics and regulation of breathing
      • lung parenchyma, including ventilation, perfusion, gas exchange
      • pleura
      • nasopharyx and sinuses
    • cell/tissue structure and function, including surfactant formation, alveolar structure
    • repair, regeneration, and changes associated with stage of life
    • pulmonary defense mechanisms and normal flora
    Abnormal processes
    • infectious, inflammatory, and immunologic disorders
      • infectious diseases
        • infectious diseases of the upper respiratory tract
        • pyogenic infectious diseases of the lower respiratory tract and pleura, viral infections, and associated complications
        • other infectious diseases of the lower respiratory tract
      • immunologic disorders
        • allergic and hypersensitivity disorders
        • autoimmune disorders
      • inflammatory disorders
        • pneumoconioses
        • acute and chronic alveolar injury
        • chronic obstructive pulmonary disease
        • restrictive pulmonary disease
    • traumatic and mechanical disorders
    • neoplastic disorders (including upper airway, lower airway and lung parenchyma, pleura, and metastatic tumors)
    • metabolic, regulatory, and structural disorders
    • vascular and circulatory disorders (including thromboembolic disease, pulmonary hypertension, pulmonary edema, and pleural effusion)
    • systemic disorders affecting the respiratory system
    • idiopathic disorders
    • degenerative disorders
    • drug-induced adverse effects on the respiratory system
    • congenital and genetic disorders affecting the respiratory system
    Principles of therapeutics
    • mechanisms of action and use of drugs for treatment of disorders of the respiratory system
      • decongestants, cough suppressants, expectorants, mucolytics
      • bronchodilator drugs
      • anti-inflammatory and cytotoxic drugs
      • antimicrobial agents and antiparasitic agents
      • antineoplastic agents
      • pulmonary vasodilators
    • other therapeutic modalities
    Gender, ethnic, and behavioral considerations affecting disease treatment and prevention, including psychosocial, cultural, occupational, and environmental
    • emotional and behavioral factors
    • influence on person, family, and society
    • occupational and other environmental risk factors
    • gender and ethnic factors

  7. Cardiovascular System
    Normal processes
    • embryonic development, fetal maturation, and perinatal changes
    • organ structure and function
      • chambers, valves
      • cardiac cycle, mechanics, heart sounds, cardiac conduction
      • hemodynamics, including systemic, pulmonary, coronary, and blood volume
      • circulation in specific vascular beds
    • cell/tissue structure and function
      • heart muscle, metabolism, oxygen consumption, biochemistry, and secretory function
      • endothelium and secretory function, vascular smooth muscle, microcirculation, and lymph flow (including mechanisms of atherosclerosis)
      • neural and hormonal regulation of the heart, blood vessels, and blood volume, including responses to change in posture, exercise, and tissue metabolism
    • repair, regeneration, and changes associated with stage of life
    Abnormal processes
    • infectious, inflammatory, and immunologic disorders
    • traumatic and mechanical disorders
    • neoplastic disorders
    • metabolic and regulatory disorders (including dysrhythmias, systolic and diastolic dysfunction, low- and high-output heart failure, cor pulmonale, systemic hypertension, ischemic heart disease, myocardial infarction, systemic hypotension and shock, and dyslipidemias)
    • vascular disorders
    • systemic diseases affecting the cardiovascular system
    • congenital and genetic disorders of the heart and central vessels
    • idiopathic disorders
    • drug-induced adverse effects on the cardiovascular system
    • degenerative disorders
    Principles of therapeutics
    • mechanisms of action and use of drugs for treatment of disorders of the cardiovascular system
      • coronary and peripheral vasodilators
      • antiarrhythmic drugs
      • antihypertensive drugs
      • measures used to combat hypotension and shock
      • drugs affecting cholesterol and lipid metabolism
      • drugs affecting blood coagulation, thrombolytic agents, and antiplatelet agents
      • inotropic agents and treatment of heart failure
      • immunosuppressive, antimicrobial, antineoplastic, and antiparasitic drugs
      • drugs to treat peripheral arterial disease
      • other pharmacotherapy
    • other therapeutic modalities
    Gender, ethnic, and behavioral considerations affecting disease treatment and prevention, including psychosocial, cultural, occupational, and environmental
    • emotional and behavioral factors
    • influence on person, family, and society
    • occupational and other environmental risk factors
    • gender and ethnic factors

  8. Gastrointestinal System
    Normal processes
    • embryonic development, fetal maturation, and perinatal changes
    • organ structure and function, including alimentary canal, liver and biliary system, salivary glands and exocrine pancreas, motility, and digestion and absorption
    • cell/tissue structure and function
      • endocrine and neural regulatory functions, including GI hormones
      • salivary, gastrointestinal, pancreatic, hepatic secretory products, including enzymes, proteins, bile salts, and processes
      • synthetic and metabolic functions of hepatocytes
    • repair, regeneration, and changes associated with stage of life
    • gastrointestinal defense mechanisms and normal flora
    Abnormal processes
    • infectious, inflammatory, and immunologic disorders
    • traumatic and mechanical disorders
      • malocclusion
      • hiatal hernia
      • obstruction
      • perforation of hollow viscus and blunt trauma
      • inguinal, femoral, and abdominal wall hernias
      • esophageal, intestinal, and colonic diverticula
    • neoplastic disorders, including benign and malignant
    • metabolic and regulatory disorders (including motility disorders, malabsorption, hepatic failure, cholelithiasis, nutritional disorders)
    • vascular disorders (including portal hypertension, esophageal varices, hemorrhoids, anal fissure, ischemia, angiodysplasia, thromboses, vasculitis)
    • systemic disorders affecting the gastrointestinal system
    • idiopathic disorders
    • degenerative disorders
    • drug-induced adverse effects on the gastrointestinal system
    • congenital and genetic disorders affecting the gastrointestinal system
    Principles of therapeutics
    • mechanisms of action and use of drugs for treatment of disorders of the gastrointestinal system
      • treatment and prophylaxis of peptic ulcer disease and gastroesophageal reflux
      • drugs to alter gastrointestinal motility
      • fluid replacement
      • pancreatic replacement therapy and treatment of pancreatitis
      • drugs for treatment of hepatic failure and biliary disease
      • anti-inflammatory, immunosuppressive, antineoplastic, antimicrobial, and antiparasitic drugs
    • other therapeutic modalities
    Gender, ethnic, and behavioral considerations affecting disease treatment and prevention, including psychosocial, cultural, occupational, and environmental
    • emotional and behavioral factors
    • influence on person, family, and society
    • occupational and other environmental risk factors
    • gender and ethnic factors

  9. Renal/Urinary System
    Normal processes
    • embryonic development, fetal maturation, and perinatal changes
    • organ structure and function
      • kidneys, ureters, bladder, urethra
      • glomerular filtration and hemodynamics
      • tubular reabsorption and secretion, including transport processes and proteins
      • urinary concentration and dilution
      • renal mechanisms in acid-base balance
      • renal mechanisms in body fluid homeostasis
      • micturition
    • cell/tissue structure and function, including renal metabolism and oxygen consumption, hormones produced by or acting on the kidney
    • repair, regeneration, and changes associated with stage of life
    Abnormal processes
    • infectious, inflammatory, and immunologic disorders
      • infectious disorders
        • upper urinary tract
        • lower urinary tract
      • inflammatory and immunologic disorders
        • glomerular disorders
        • tubular interstitial disease
    • traumatic and mechanical disorders
    • neoplastic disorders, including primary and metastases
    • metabolic and regulatory disorders
      • renal failure, acute and chronic
      • tubular and collecting duct disorders
      • renal calculi
    • vascular disorders
    • systemic diseases affecting the renal system
    • idiopathic disorders
    • degenerative disorders
    • drug-induced adverse effects on the renal/urinary system
    • congenital and genetic disorders affecting the renal/urinary system
    Principles of therapeutics
    • mechanisms of action and use of drugs for treatment of disorders of the renal and urinary system
      • diuretics, antidiuretic drugs
      • drugs and fluids used to treat volume, electrolyte, and acid-base disorders
      • drugs used to enhance renal perfusion
      • anti-inflammatory, antimicrobial, immunosuppressive, antineoplastic, and antiparasitic drugs
      • drugs used to treat lower urinary tract system
    • other therapeutic modalities
    Gender, ethnic, and behavioral considerations affecting disease treatment and prevention, including psychosocial, cultural, occupational, and environmental
    • emotional and behavioral factors
    • influence on person, family, and society
    • occupational and other environmental risk factors
    • gender and ethnic factors

  10. Reproductive System
    Normal processes
    • embryonic development, fetal maturation, and perinatal changes, including gametogenesis
    • organ structure and function
      • female structure, including breast
      • female function
      • male structure
      • male function
      • intercourse, orgasm
      • pregnancy, including ovulation, fertilization, implantation, labor and delivery, the puerperium, lactation, gestational uterus, placenta
    • cell/tissue structure and function, including hypothalamic-pituitary-gonadal axis, sex steroids, and gestational hormones
    • reproductive system defense mechanisms and normal flora
    Abnormal processes
    • infectious, inflammatory, and immunologic disorders (female and male)
    • traumatic and mechanical disorders (female and male)
    • neoplastic disorders (including female reproductive, male reproductive, breast [including fibrocystic changes], trophoblastic disease)
    • metabolic and regulatory processes (female and male)
    • prenatal and perinatal counseling and screening
    • systemic disorders affecting reproductive function
    • disorders relating to pregnancy, the puerperium, and the postpartum period
      • obstetric problems
      • complications affecting other organ systems
      • disorders associated with the puerperium
      • antepartum, intrapartum, postpartum disorders of the fetus
    • idiopathic disorders
    • drug-induced adverse effects on the reproductive system
    • degenerative disorders
    • congenital and genetic disorders affecting the reproductive system
    Principles of therapeutics
    • mechanisms of action and use of drugs for treatment of disorders of the reproductive system and management of normal reproductive function
      • female reproductive tract
        • fertility drugs
        • oral contraception, other methods of contraception
        • estrogen, progesterone replacement, treatment of menopause
        • stimulants and inhibitors of labor
        • estrogen and progesterone antagonists
        • stimulators and inhibitors of lactation
      • male reproductive tract
        • fertility drugs
        • androgen replacement and antagonists
      • gonadotropin-releasing hormone and gonadotropin replacement, including all gonadotropin-releasing hormone antagonists
      • abortifacients
      • antimicrobial and antiparasitic agents
      • antineoplastics
      • restoration of potency
    • other therapeutic modalities affecting the reproductive system
    Gender, ethnic, and behavioral considerations affecting disease treatment and prevention, including psychosocial, cultural, occupational, and environmental
    • emotional and behavioral factors
    • influence on person, family, and society
    • occupational and other environmental risk factors
    • family planning and pregnancy
    • gender identity, sexual orientation, sexuality, libido
    • effects of traumatic stress syndrome, violence, rape, child abuse

  11. Endocrine System
    Normal processes
    • embryonic development, fetal maturation, and perinatal changes
    • organ structure and function
      • hypothalamus, posterior and anterior pituitary gland
      • thyroid gland
      • parathyroid glands
      • adrenal cortex, adrenal medulla
      • pancreatic islets
      • ovary and testis
      • adipose tissue
    • cell/tissue structure and function, including hormone synthesis, secretion, action, and metabolism
      • peptide hormones
      • steroid hormones, including vitamin D
      • thyroid hormones
      • catecholamine hormones
      • renin-angiotensin system
    • repair, regeneration, and changes associated with stage of life
    Abnormal processes
    • infectious, inflammatory, and immunologic disorders
    • traumatic and mechanical disorders
    • neoplastic disorders (including pituitary, thyroid, parathyroid, adrenal cortex, pancreatic islets, neural crest, pheochromocytoma)
    • metabolic and regulatory processes (including diabetes mellitus, pituitary, hypothalamus, thyroid, parathyroid, pancreatic islet disorders, adrenal disorders)
    • vascular disorders
    • systemic disorders affecting the endocrine system
    • idiopathic disorders
    • degenerative disorders
    • drug-induced adverse effects on the endocrine system
    • congenital and genetic disorders affecting the endocrine system
    Principles of therapeutics
    • mechanisms of action and use of drugs for treatment of disorders of the endocrine system
      • hormones and hormone analogs
      • stimulators of hormone production
      • inhibitors of hormone production
      • hormone antagonists
      • potentiators of hormone action
      • antiobesity agents
      • nonhormonal therapy for endocrine disorders
      • other treatment for diabetes
    • other therapeutic modalities
    Gender, ethnic, and behavioral considerations affecting disease treatment and prevention, including psychosocial, cultural, occupational, and environmental
    • emotional and behavioral factors
    • influence on person, family, and society
    • occupational and other environmental risk factors
    • gender and ethnic factors

  12. Immune System
    Normal processes
    • development of cells of the adaptive immune response, including positive and negative selection during immune development
    • structure, production, and function
      • granulocytes, natural killer cells, macrophages, mast cells, dendritic cells, cell receptors
      • T lymphocytes, including T-lymphocyte receptors, accessory molecules, cell activation and proliferation, cytotoxic T lymphocytes, and memory T lymphocytes
      • B lymphocytes and plasma cells, including B-lymphocyte receptors, immunoglobulins, cell activation and proliferation, including development of antibodies and memory B lymphocytes
      • structure and function of lymph nodes, host defense mechanisms, host barriers to infection, mucosal immunity
      • immunogenetics
      • Rh and ABO antigens, including genetics
    • cellular basis of the immune response and immunologic mediators
      • antigen processing and presentation in the context of MHC I and MHC II molecules, including distribution of MHC I and MHC II on different cells, mechanism of MHC I and MHC II deficiencies, and the genetics of MHC
      • regulation of the adaptive immune response
      • activation, function, and molecular biology of complement
      • function and molecular biology of cytokines
    • basis of immunologic diagnosis
    Abnormal processes
    • disorders with alterations in immunologic function
      • abnormalities in adaptive immune responses
      • deficiencies of phagocytic cells and natural killer cells
      • complement deficiency
      • HIV infection/AIDS
      • Non-HIV infections of lymphocytes
      • systemic diseases of immunologic function
      • systemic disorders affecting the immune system and the effect of age on the function of components of the immune system
    • immunologically mediated disorders
      • type I, type II, type III hypersensitivity
      • type IV hypersensitivity
      • transplantation risks and rejection, including transfusion reactions
      • isoimmunization, hemolytic disease of the newborn
    • drug-induced adverse effects on the immune system, including Jarisch-Herxheimer
    Principles of therapeutics
    • mechanisms of action and use of drugs that specifically affect immune function
      • vaccines (active and passive)
      • antiretrovirals
      • immunomodulating and antineoplastic drugs
      • biologics, including monoclonal and polyclonal antibodies
    • other therapeutic modalities
    Gender, ethnic, and behavioral considerations affecting disease treatment and prevention, including psychosocial, cultural, occupational, and environmental
    • emotional and behavioral factors
    • influence on person, family, and society
    • occupational and other environmental risk factors
    • gender and ethnic factors

Test Question Formats

Step 1 consists of multiple choice questions with only one best answer. Each question will be structured with a statement or question followed by three to eleven response options, each labeled with a letter (e.g: A, B, C, D, E) and arranged logically or alphabetically. Some response options will be partially correct, but only one option will be the best and correct answer. A portion of these questions will also involve the interpretaion of graphs and images.
The questions are prepared by examination committees composed of faculty members, teachers, investigators, and clinicians with recognized prominence in their respective fields. Committee members are selected to provide broad representation from the academic, practice, and licensing communities across the United States and Canada.

Strategies for Answering the Test Questions


  • Read each question carefully. It is important to understand what is being asked.
  • Try to generate an answer and then look for it in the option list.
  • Alternatively, read each option carefully, eliminating those that are clearly incorrect.
  • Of the remaining options, select the one that is most correct.
  • If unsure about an answer, it is better to guess since unanswered questions are automatically counted as wrong answers.
Example Question
A 32-year-old woman with type 1 diabetes mellitus has had progressive renal failure over the past 2 years. She has not yet started dialysis. Examination shows no abnormalities. Her hemoglobin concentration is 9 g/dL, hematocrit is 28%, and mean corpuscular volume is 94 m3. A blood smear shows normochromic, normocytic cells. Which of the following is the most likely cause?
  • Acute blood loss
  • Chronic lymphocytic leukemia
  • Erythrocyte enzyme deficiency
  • Erythropoietin deficiency
  • Immunohemolysis
  • Microangiopathic hemolysis
  • Polycythemia vera
  • Sickle cell disease
  • Sideroblastic anemia
  • b-Thalassemia trait
(Answer: D)

Sequential Item Sets


A single patient-centered vignette may be associated with two or three consecutive questions about the information presented. Each question is linked to the initial patient vignette but is testing a different point. Questions are designed to be answered in sequential order. You are required to select the one best answer to each question. Other options may be partially correct, but there is only ONE BEST answer. You must click "Proceed to Next Item" to view the next item in the set; once you click on this button, you will not be able to add or change an answer to the displayed (previous) item.

Test Length and Format

Step 1 has approximately 322 multiple-choice test items. This is divided into 7 blocks of 46 items; 60 minutes are allotted for completion of each block of test items and administered in one eight hour testing session. For Step 1, during the defined time to complete the items in each block, you may answer the items in any order, review your responses, and change answers. After you exit the block, or when time expires, you can no longer review test items or change answers.On the test day, examinees have a minimum of 45 minutes of break time and a 15- minute optional tutorial. The amount of time available for breaks may be increased by finishing a block of test items or the optional tutorial before the allotted time expires.

Eligibility Criteria

To be eligible to take the USMLE Step 1, you must be in one of the following categories at the time of application and on the test day:
  • a medical student officially enrolled in, or a graduate of, a US or Canadian medical school program leading to the MD degree that is accredited by the Liaison Committee on Medical Education (LCME),
  • a medical student officially enrolled in, or a graduate of, a US medical school leading to the DO degree that is accredited by the American Osteopathic Association (AOA), or
  • a medical student officially enrolled in, or a graduate of, a medical school outside the United States and Canada and eligible for examination by the ECFMG.
          

    Disclaimer The information presented on this page is taken from the official USMLE website www.usmle.org.Please refer to the official USMLE website for further information regarding USMLE requirements, scheduling your exam and the application process.