USMLE: An In-Depth Guide

The USMLE (United States Medical Licensing Examination) is a three-step exam for medical licensure in the U.S. It is sponsored and administered by the Federation of State Medical Boards (FSMB) and the National Board of Medical Examiners (NBME).

To become a licensed physician, you’ll need to take USMLE Step 1 after year two of medical school, USMLE Step 2 after year three of med school, and USMLE Step 3 once you start medical residency.

To be eligible to take the USMLE, you need to be a student or graduate of a med school accredited by the Liaison Committee on Medical Education (LCME). IMGs must meet specific eligibility criteria set by the Educational Commission for Foreign Medical Graduates (ECFMG).

Below, we’ll take you through each USMLE step, what they cover, timelines, scoring, and top tips from experts who have taken the USMLE and coached people like you to their target score.

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USMLE Step 1

USMLE Step 1 is a pass/fail exam usually required to begin clinical rotations. It assesses a medical student's foundational knowledge of basic science principles and the practical application of clinical medicine.

When do you take it? Typically, you take Step 1 at the end of your second year in medical school, between February and the summer. This exam is designed to be taken after completing pre-clinical coursework and before starting clinical rotations in year three.

What’s the format? You will take Step 1 in one 8-hour session, divided into seven 60-minute blocks, plus an optional 15-minute tutorial and a 45-minute break. This computer-based test consists of multiple-choice questions, with 40 questions at most per section. Total questions won’t exceed 280.

Be Prepared: Everything You Need to Know About USMLE Test Day

How is it scored? Step 1 is scored on a pass/fail grading system, which replaced the three-digit grading scale in 2022. The percentage of correct answers needed for a passing grade varies year to year, but you generally need to answer more than 60% of questions correctly to pass. Learn more about how this pass/fail change impacts IMGs.

How many people pass? Domestic test takers pass Step 1 about 90% of the time — though this stat includes retesters who have a pass rate of 70%. Test takers from outside the U.S. pass about 70% of the time, including repeat testers, who pass about 53% of the time.

What does it cover? Check out this table of what disciplines are covered on Step 1, as well as how much each discipline may show up on the exam. This table should help you know how to study, but you can also check out our study guide for Step 1.

Discipline	Range %
Pathology	45-55
Physiology	30-40
Gross Anatomy & Embryology	10-20
Microbiology	10-20
Pharmacology	10-20
Behavioral Sciences	10-15
Biochemistry & Nutrition	5-15
Immunology	5-15
Histology & Cell Biology	5-15
Genetics	5-10

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USMLE Step 2 CK (Clinical Knowledge)

USMLE Step 2 CK is an exam assessing a medical student's application of clinical science knowledge to patient care (under supervision). The “CK” stands for “Clinical Knowledge.” Passing Step 2 is almost universally required to apply to medical residency.

There used to be another Step 2 exam required alongside CK — called USMLE Step 2 CS (Clinical Skills) — but Step 2 CS was discontinued temporarily during COVID and discontinued permanently as of 2021.

When do you take it? Typically, you take Step 2 CK at the end of your third year in medical school. This exam is meant to be taken right before applying to residency programs.

What’s the format? You’ll take Step 2 in a single 9-hour test session, divided into eight 60-minute blocks. This computer-based, multiple-choice test will feature no more than 318 health science questions — at most 40 questions per 60-minute block. There’s an optional 15-minute tutorial, and a minimum of 45 minutes allotted for break time.

We recommend you run the Step 2 CK interactive testing experience to get familiar with the Step 2 test software before your test date.

How is it scored? Step 2 is scored on a three-digit scale ranging from 1-300. In 2025, the minimum passing score was raised to 218 (bottom 3% of test takers). However, if you want to match into a competitive specialty, aim for a score of at least 250-255. Learn more about Step 2 scores here.

How many people pass? Domestic test takers pass Step 2 CK about 97% of the time — this stat includes repeat testers with a pass rate of 72%. Test takers from outside the U.S. have a pass rate of about 87% — including repeaters who pass about 63% of the time.

Because Step 1 is now pass/fail, scoring well on Step 2 is more important for residency applications than it used to be, and perhaps more stress-inducing. Check out our Step 2 Score Estimator to determine what score you should aim for to make it into the specialty of your choice.

What does it cover? Check out this table on what disciplines are covered on USMLE Step 2, plus how much each discipline could appear on the test. Check out our curated Step 2 Study Guide for more comprehensive guidance.

Discipline	Range %
Medicine	55-65
Surgery	20-30
Pediatrics	17-27
Obstetrics & Gynecology (OBGYN)	10-20
Psychiatry	10-15

USMLE Step 3: Final Licensing Exam

USMLE Step 3 is a two-day exam which is the final step towards general medical licensure. Day one assesses your knowledge of basic medical, scientific, and even social principles essential for effective health care. Day two assesses your patient care and disease management skills.

When do you take it? You’ll take Step 3 during residency, generally at the end of PGY-1 or the beginning of PGY-2.

What’s the format? Step 3 is taken over two exam days:

The first day includes an optional 5-minute tutorial, followed by 232 multiple-choice questions divided into six 60-minute blocks of 38-39 items. You get at least 45 minutes for break time. Day one typically takes 7 hours.
The second day includes an optional 5-minute tutorial, followed by 180 multiple-choice questions, divided into six 45-minute blocks of 30 items. The second day then features a 6-minute tutorial on computer-based case simulations, followed by 13-14 case simulations (not multiple-choice), each of which is allotted 10 or 20 minutes to complete. You get at least 45 minutes for break time. There’s an optional survey at the end of the second day. Day two typically takes 9 hours.

We recommend you run the updated Step 3 interactive testing experience to get totally familiar with the Step 3 testing software prior to test day.

How is it scored? Step 3 is scored on a three-digit scale. Both multiple-choice items and case simulations contribute to your score. Case simulations are scored based on how appropriately you manage the case, not a single “correct” path. In 2024, the minimum passing score was raised from 198 to 200.

How many people pass? Generally, about 97% of domestic test takers and 90% of non-U.S. test takers pass Step 3. Repeat test takers have about a 75% pass rate for domestic testers and 64% pass rate for non-U.S. testers.

What does it cover? Below is a table of content specifications covered on Step 3, separated into what’s covered on multiple-choice questions versus the non-multiple-choice case simulations. Check out our Step 3 Study Guide for comprehensive assistance.

Systems Covered on Multiple-Choice Questions	Range %
Human Development (Normal Age-Related Findings & Care of the Well Patient)	1-3
Immune System, Blood & Lymphoreticular System, and Multisystem Processes/Disorders	6-8
Behavioral Health	4-6
Nervous System & Special Senses	8-10
Skin & Subcutaneous Tissue	4-6
Musculoskeletal System	5-7
Cardiovascular System	9-11
Respiratory System	8-10
Gastrointestinal System	6-8
Renal/Urinary & Male Reproductive Systems	4-6
Pregnancy/Childbirth & Female Reproductive System & Breast	7-9
Endocrine System	5-7
Biostatistics & Epidemiology/Population Health & Interpretation of the Medical Literature	11-13
Social Sciences: Communication Skills/Ethics/Patient Safety	7-9

Categories Covered in Computer-Based Case Simulations	Covered
Immune System	✅
Blood & Lymphoreticular System	✅
Behavioral Health	✅
Nervous System & Special Senses	✅
Skin & Subcutaneous Tissue	✅
Musculoskeletal System	✅
Cardiovascular System	✅
Respiratory System	✅
Gastrointestinal System	✅
Renal & Urinary System	✅
Pregnancy, Childbirth, & the Puerperium	✅
Female Reproductive & Breast	✅
Male Reproductive	✅
Endocrine System	✅
Multisystem Processes & Disorders	✅
Biostatistics & Epidemiology/Population Health & Interpretation of the Medical Literature	Possibly, not definitely
General Principles of Foundational Science	Possibly, not definitely
Social Sciences	Possibly, not definitely

When Do You Take Each Step?

Here’s a basic timeline for when to take each USMLE Step:

When to study for USMLE Step 1: Middle of 2nd year of medical school
When to take USMLE Step 1: End of 2nd year in medical school or in summer after 2nd year, before clinical rotations
When to study for USMLE Step 2 CK: Middle of 3rd year of medical school
When to take USMLE Step 2 CK: End of 3rd year in medical school or beginning of 4th year, before applying to residency
When to study for USMLE Step 3: During your intern year of medical residency (PGY-1)
When to take USMLE Step 3: During residency, at the end of PGY-1 or beginning of PGY-2

International medical graduates (IMGs) don’t have a standard USMLE timeline like those attending U.S. medical schools. While many IMGs take Step 1 before applying for U.S. clinical rotations, the timing depends on your school structure and personal strategy. In some cases, you may delay Step 1 if your rotation plans allow it.

7-Year Rule

For most medical students, there’s a 7-year rule you must abide by. Most state medical boards require you to pass the USMLE Step 3 within 7 years of passing USMLE Step 1. If it’s been more than 7 years, you probably have to retake one or more of the exams.

There are several exceptions to this 7-year rule since every state board can make its own rules:

California, Indiana, Iowa, Kansas, Louisiana, Nebraska, Ohio, Oklahoma, South Carolina, Virginia, West Virginia, and Wisconsin allow medical students 10 years to pass all the USMLE Step exams.
If you’re an MD/PhD dual-program student, Alaska, Colorado, New Mexico, South Dakota, and Utah allow 10 years to complete all Steps. Georgia allows 9 years for MD/PhD students.
The following states have no time limit for completing all Steps: Arkansas, Connecticut, Florida, Hawaii, Idaho, Kentucky, New Hampshire, New York, and the territory of Guam.

Tips for Exam Preparation

USMLE test prep is essential. If you pass a step, you typically cannot retake it. You can retake after a failure, but a failure is a huge red flag on residency applications. So you want to put your best foot forward from the get-go.

Below are some expert tips from MedSchoolCoach Tutors who have helped people like you pass the USMLE with competitive scores:

Determine when you’ll take Step 1 early on. Consult your academic advisor or administration at the start of your 2nd year in med school. Check out more proven strategies for Step 1 in this free webinar.
Give yourself at least 3 months to study, so you don’t have to cram at the last minute. We recommend a low-stress 6-month study schedule if you can fit it into your calendar, especially if you have a history of poor test-taking.
Set yourself up for success by considering USMLE tutoring. MedSchoolCoach offers personalized tutoring services, and you can choose the tutoring service that works best for your unique circumstances.
Decide on your test date, keeping in mind how long it takes to get your Step 2 scores back, as this may affect your residency application timeline. USMLE score reports are released 2-4 weeks after taking the test.
Check out our free guidebook on getting ready for Step 1 and Step 2 CK, including what books and question banks best prepare you for test day.
Take plenty of practice tests. Use AMBOSS or UWorld question banks. We would not recommend any other Qbanks because AMBOSS and UWorld are by far the best common question bank resources, which include comprehensive explanations of why individual answers are right or wrong. Learn more tricks for the USMLE Step 2 here.
Try to find little bursts of time to do 5 practice questions at a time. It’s difficult to find time for Step 2 or Step 3 studies during rotations, so it’s best to seek out small time gaps and use them to your advantage. You could aim to complete 20 practice questions by noon and another 20 by 5:00 PM.
Download our free guidebook on Mastering Step 3 to create an effective study schedule, maximize study resources, and balance your life and studying.

Costs and Registration

Registering for USMLE test dates requires payment of registration fees to NBME.

Here is how much it costs to take the different USMLE steps in 2026:

Step 1: $695
Step 2 CK: $695
Step 3: $955

For exams taken outside the U.S., there is an additional fee that is not collected by USMLE:

Step 1 outside the U.S.: An additional $210
Step 2 CK outside the U.S.: An additional $235

To extend your eligibility period to take Step 1 or Step 2, it costs $70.

The NBME offers a Fee Assistance Program to medical students who demonstrate financial need. Only available to eligible U.S. test takers for Step 1 and Step 2 CK, NBME is offering a reimbursement — not a fee waiver — that likely covers the full cost of one exam.

FAQs

The majority of test takers seem to agree that the USMLE steps are tough but fair. It has been described as appropriately difficult for the demands of becoming a physician.

Passing the USMLE is not nearly as hard as getting a competitive score. There are a lot of free and affordable study resources to make your USMLE journey easier.

You can retake Step 1 four times before you’re ineligible to take any further USMLE tests.

Your fourth attempt must be at least 12 months after your first attempt and at least 6 months after your most recent attempt.

In 2021, USMLE reduced the maximum number of attempts from six to four — partly because after the fourth attempt, almost no one passed anyway.

Many consider the USMLE to be harder than the MCAT.

While the MCAT (Medical College Admission Test) covers pre-medical knowledge, USMLE Step 1 covers the first two years of medical school (pre-clinical knowledge), and Step 2 CK generally covers three years of med school. So the breadth of content is wider with the USMLE.

Also, you can retake the MCAT to increase your score. If you pass the USMLE, even with a low score, you’re usually not allowed to retake it. So there’s more pressure to score high on Step 2 for residency applications than scoring high on the MCAT for med school applications.

Finally, the USMLE testing days are widely considered to be a little tougher than the MCAT testing day. USMLE test days are slightly longer, and there are four days of testing across three steps — instead of the MCAT, which doesn’t have multiple steps.

MD (Allopathic) students generally need to pass USMLE Step 1 to begin clinical rotations, while DO (Osteopathic) students generally need to pass COMLEX Level 1 to begin clinical rotations.

Though only required to take COMLEX, some DO students choose to take both COMLEX Level 1 and USMLE Step 1 to be more competitive for certain residency programs.

Most doctors need to complete all three steps of the USMLE to work as a licensed doctor in the U.S. Exceptions primarily apply to IMGs who graduated from a non-U.S. school of medicine.

Some states allow international medical graduates (IMGs) to work in specific medical jobs in those states without completing the USMLE. Often, IMGs are restricted to work alongside other physicians (such as in medical education settings) for a few years before being allowed to practice medicine solo.

Usually, the “replacement” for the USMLE is ECFMG certification plus several years of eligible postgraduate training in another country.

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USMLE refers to three distinct tests typically taken over the course of 3-7 years. Step 1 is pass/fail, while Step 2 and Step 3 are scored on a three-digit scale. Getting good USMLE scores is vital to your journey to becoming a physician.

Step 1 and Step 2 CK are usually required to apply to medical residency. Completing all three steps is generally required by state medical boards to obtain a license to practice medicine in that state.

Don’t leave your USMLE scores to chance — consider professional tutoring to increase your chances of success.

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