Step 2 assesses whether you can apply medical knowledge, skills, and understanding of clinical science essential for the provision of patient care under supervision and includes emphasis on health promotion and disease prevention. Step 2 ensures that due attention is devoted to principles of clinical sciences and basic patient-centered skills that provide the foundation for the safe and competent practice of medicine.
Step 2 CK is constructed according to an integrated content outline that organizes clinical science material along two dimensions: physician task and disease category.
Step 2 CK is a one-day examination. The test items are divided into blocks, and test item formats may vary within each block.
The number of items in a block will be displayed at the beginning of each block. This number will vary among blocks, but will not exceed 45 items. The total number of items on the overall examination form will not exceed 355 items. Regardless of the number of items, 60 minutes are allotted for the completion of each block.
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.
Step 2 Clinical Knowledge (Step 2 CK) 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.
Test questions focus on the principles of clinical science that are deemed important for the practice of medicine under supervision in postgraduate training.
Content Outline and Specifications
The USMLE Content Outline provides a common organization of content across all USMLE examinations. In addition, the USMLE Physician Tasks/Competencies, outline lists tasks and competencies assessed throughout the sequence of USMLE.
The USMLE Content Outline organizes content according to general principles and individual organ systems. Test questions are classified in one of 18 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, including principles of therapy.
While not all topics listed in the content outline are included in every USMLE examination, overall content coverage is comparable in the various examination forms that will be taken by different examinees for each Step.
Most organ systems are partitioned into normal and abnormal processes, including subcategories of specific disease processes. In most instances, knowledge of normal processes is evaluated in the context of a disease process or specific pathology. (See Tables 1 and 2 below.)
The content outline 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.
Table 1: USMLE Step 2 CK Test Specifications*
Blood & Lymphoreticular Systems
Nervous System & Special Senses
Skin & Subcutaneous Tissue
Renal & Urinary Systems
Pregnancy, Childbirth, & the Puerperium
Female Reproductive System & Breast
Male Reproductive System
Multisystem Processes & Disorders
Interpretation of the Medical Literature
* Percentages are subject to change at any time. See the USMLE Web site for the most up-to-date information.
** The general principles category for the Step 2 CK examination includes test items concerning normal processes not limited to specific organ systems. These test items are typically related to normal development. Categories for individual organ systems include test items concerning those normal and abnormal processes that are system-specific.
An additional organizing construct for Step 2 CK design is physician tasks and competencies, as shown in Table 2. Items are constructed to focus on assessing one of the following competencies:
- Medical knowledge/scientific concepts: Applying foundational science concepts
- Patient care: Diagnosis
- Patient care: Management
- Communication and interpersonal skills
- Professionalism, including legal and ethical issues
- Systems-based practice, including patient safety
- Practice-based learning, including biostatistics and epidemiology
Table 2: Step 2 CK Physician Task/Competency Specifications
- History/Physical Examination
- Laboratory/Diagnostic Studies
- Clinical Interventions
- Mixed Management
- Surveillance for Disease Recurrence
Systems-based Practice/Patient Safety
- 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.
This is the traditional, most frequently used multiple-choice format. It consists of a vignette and question followed by three to twenty-six options that are in alphabetical or logical order. The response options in this format are lettered (eg, A, B, C, D, E). You are required to select the one best answer to the question. Other options may be partially correct, but there is only ONE BEST answer.
Items with an associated pharmaceutical ad or abstract were introduced into the examination in August 2011. Each pharmaceutical ad or abstract appears as a 2- or 3-item set; there are no more than 5 of these item sets in each examination. Because item sets with an associated pharmaceutical ad or abstract may require more time to answer than traditional multiple-choice items, blocks that include a pharmaceutical ad or abstract item set contain fewer items.
A 32-year-old woman with type 1 diabetes mellitus has had progressive renal failure over the past 2 years. She is not yet on 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
- Microangiopathic hemolysis
- Polycythemia vera
- Sickle cell disease
- Sideroblastic anemia
- β-Thalassemia trait
Sequential Item Sets
A single patient-centered vignette may be associated with two or three consecutive questions about the information presented. Each question is associated with the initial patient vignette but is testing a different point. You are required to select the ONE BEST answer to each question. Questions are designed to be answered in sequential order. You must click “Proceed to Next Item” to view the next item in the set; once you click on this button,the next question will be displayed, and you will not be able to return to the previous question or change the answer to it.
Matching Item Sets
This format consists of a series of questions related to a common topic. All matching sets contain set-specific instructions, a list of lettered response options, and at least two questions. There will be between four and twenty-six response options. Each set is preceded by a box that indicates the number of questions in the set associated with the response options that follow. Examinees are directed to select one answer for each question in the set. Questions will be presented one at a time, with instructions and response options repeated for each subsequent question.
Strategies for Answering Matching Sets
- Begin each set by reading through the option list to become familiar with the available responses.
- Read each question carefully.
- Within a set, some options may be used several times, while other options may not be used at all. Respond to each question independently.
- For matching sets with large numbers of options, try to generate an answer to the question and then locate the answer in the option list. This is more efficient than considering each option individually.
Example Questions (Matching Set)
(The response options for items 2-3 are the same. You will be required to select one answer for each item in the set. )
- Chronic lymphocytic leukemia
- Drug reaction
- Hodgkin disease
- Infectious mononucleosis
- Metastatic carcinoma
- Systemic lupus erythematosus
For each patient with lymphadenopathy, select the most likely diagnosis.
2. A previously healthy 30-year-old man has had fever, night sweats, pruritus, and an enlarging lump above his left clavicle for 3 weeks. Examination shows a 3-cm, nontender, rubbery, supraclavicular lymph node. An x-ray of the chest shows mediastinal lymphadenopathy.
3. A 41-year-old woman comes to the physician for a follow-up examination. She has taken aspirin for chronic headaches and phenytoin for a seizure disorder for 2 years. Examination shows mild epigastric tenderness and bilateral, 3-cm, nontender axillary lymph nodes. A lymph node biopsy shows hyperplasia.
Pharmaceutical Advertisement (Drug Ad) Format
The drug ad item format includes a rich stimulus presented in a manner commonly encountered by a physician, eg, as a printed advertisement in a medical journal. Examinees must interpret the presented material in order to answer questions on various topics, including
- Decisions about care of an individual patient
- Development and approval of drugs and dietary supplements
- Medical ethics
The abstract item format includes a summary of an experiment or clinical investigation presented in a manner commonly encountered by a physician, eg, as an abstract that accompanies a research report in a medical journal. Examinees must interpret the abstract in order to answer questions on various topics, including
- Decisions about care of an individual patient
- Use of diagnostic studies