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OverseasDiaries Issue 2: A look at the USMLE

Updated: Jan 21, 2021


So in the last article, we explored one of the most popular countries that med students from Pakistan (and around the world) dream of going to after they’re done with med school; US. We briefly glanced over some of the pros and cons of applying to and living in the country and agreed that while it’s a fantastic place, it would, as with most things in life, suit some people more than others.

Say you are one of those people, however. What exactly is the route?


Given the extreme level of competition in the US, and it’s incredibly high standards of professional excellence, you need to have a variety of things on your application to stand out such as a strong CV with as much quality research as possible, the experience of electives, glowing letters of recommendations (LORs), an overall ranking near the top of your class, etc. Of course, it's not to say that you can't make it without ticking all those boxes(many people do, and luck obviously plays a huge role ) but the increasing competition means everyone will definitely be aspiring to do everything possible to stand out.

But today the discussion is going to be about the most important step of all; the actual UMSLE.


Every medical graduate (international or even local) who wishes to practice medicine in the US must give (and score well in) an exam called the United States Medical Licensing Exam (USMLE). As you might’ve guessed, acing this examination is absolutely critical!



The USMLE must be given in 3 steps:


Step 1


Step 1 is basically a written test that is taken in Pakistan (or whichever country the graduate belongs to) much like the CIE examinations were conducted in O/A Levels. It is completely based on the basic sciences we study in our first 2-3 years of med school and tests our understanding of these concepts. Step 1 is a one-day examination. However, the exam itself is extremely lengthy being divided into seven 60-minute blocks and administered in one 8-hour testing session!!😥😮😫It goes without saying that it would take A LOT of studying to prepare for that exam which is why a lot of students even start preparing for it as early as their 2nd and 3rd years of med school and end up giving it around that time too!



At least that was the standard path before the switch last year; from 2022 onwards now, Step 1 will be Pass/ Fail which means no numeric scores anymore. Not in the same way as before. Talk about throwing a bombshell! (Discussion on why that could be a double-edged sword in other articles).


Step 2


Step 2 is divided into 2 further steps:


  • The name might just give it away: Step 2 Clinical Knowledge (CK) assesses our ability to apply medical knowledge and understanding of clinical science; essential for the provision of patient care under supervision and includes an emphasis on health promotion and disease prevention. It’s actually quite similar to Step 1. Step 2 CK is a one-day examination. Again, this is also a 9-hour long exam!



  • Step 2 CS is not a theoretical exam but rather a practical one and uses standardized patients to test medical students and graduates on their ability to gather information from patients, perform physical examinations, and communicate their findings to patients and colleagues. Due to its nature, it is only conducted in the US and Pakistani (and all non-US students have to travel to the US to give it.


Step 3:


This one is slightly different as compared to the other ones because it’s not actually necessary to give this one before you start with residency. In fact, many students give it during their residency or even after.


Step 3 basically assesses whether you can provide appropriate healthcare and general treatment for patients in a completely unsupervised and independent situation according to the standards required of any US physician. Special emphasis is placed on patient management in outpatient settings (this basically refers to places outside the traditional hospital setting like clinics).



The good news is that Step 3 is your final examination and the end of this nightmare. However, just like the first 2, this step is also an extremely extensive one spread out over 2 days:


  • The first day of testing is a written MCQ test which is approximately 7 hours long!


  • There are approximately 9 hours in the test session on the second day. This test day includes multiple-choice questions and computer-based case simulations.



Confused? Intimidated? Worried? I certainly am. Just writing about this got my stress levels up several folds. But thankfully, among the despair, a few statistics are encouraging: Data from the OECD in fact shows that Pakistanis make up the 2nd largest percentage of foreign doctors in the US. This means that it is certainly very possible for Pakistani graduates to make it in the US and craft a very nice life for themselves so don’t lose hope! :)


So that’s it for now! In further articles, we’ll explore more countries and their licensing exams among other things, as well as discuss the similarities and differences between them to make sure we make a well-informed decision! :)


“Study hard, for the well is deep, and our brains are shallow.”

― Richard Baxter, The Reformed Pastor



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