CRU Updates - August 2007

Posted: August 15th, 2007


The United States Medical Licensing Examination (USMLE) program provides a single pathway for primary licensure of all graduates of LCME-accredited medical schools in the United States and Canada, and all international medical graduates seeking post graduate training and licensure in the United States. The USMLE is open to graduates of accredited osteopathic medical schools, although graduates of these schools may also meet state licensure requirements by completion of the three components of the osteopathic licensure examination program. For candidates who meet all educational requirements for licensure, successful completion of the three Steps of USMLE certifies that the individual has the minimum knowledge and clinical skills for the unsupervised, general practice of medicine

The principal mission of the USMLE is to provide state licensure boards with the valid and reliable independent assessments needed to support their responsibilities for granting the primary license to practice medicine. The USMLE also has important secondary uses. Undergraduate medical schools use USMLE results for curriculum assessment, promotion, and graduation decisions. USMLE results are considered by residency program directors during the residency selection process. International graduates must pass Step 1, Step2 CK, and Step 2 CS of the USMLE for ECFMG certification.

Since its inception in the early 1990s, USMLE has evolved. The initial paper-and-pencil multiple-choice examinations moved to computer-based administration in 1999, and computer-based case simulations were added. In 2004, the Step 2 Clinical Skills examination became part of USMLE. In addition, throughout the history of USMLE, content outlines and test content of each Step examination have continuously changed, to keep pace with the evolution of medical practice and education. Nevertheless, since it was first designed nearly two decades ago, there has been no in-depth review of the entire USMLE program to ensure that the overall design, structure, and format of USMLE is effectively meeting the needs of primary and secondary users. In January 2004, the Composite Committee that governs the USMLE requested the NBME, FSMB, and ECFMG to develop a process to undertake such a review. This project is called the Comprehensive Review of USMLE (CRU).

This primary responsibility for this review was given to the Committee to Evaluate the USMLE Program (CEUP), which includes members who bring the perspective of students, residents, fellows, Deans and Associate Deans, basic science and clinical faculty, international medical graduates, state medical boards, practicing physicians, and the public to this process. Some, but not all members of the committee have had previous experience in the USMLE program as item writers, reviewers, or test committee members.

To inform CEUP, staff members have used surveys and focus groups to gather information about the impact and relevance of the USMLE program from a wide range of individuals and organizations, including a broad sampling of representatives from the medical licensing authorities and from the US undergraduate and graduate education communities. Input has also been sought from institutional and national leaders from the international medical education community. Recent USMLE examinees, both US-trained and internationally-trained, have been surveyed, as have leaders of local and national student groups.

Progress to Date

CEUP began its work in late 2006. Early in this process, the group developed a framework of general principles to guide their deliberations: 1) the first priority is to assure medical licensing authorities that a licensure candidate possesses the knowledge and skills for safe and effective patient care in both the supervised and unsupervised practice settings; 2) the USMLE has other stakeholders, and reasonable secondary uses of the USMLE results should be supported as long as they do not compromise the primary purpose of the USMLE; 3) for all uses, the assessment instruments used in the USMLE should be valid and reliable measures of the competencies required for medical practice; and 4) as one element of the licensure process, the USMLE must continue to reflect the evolving national consensus of competency.

Although CEUP has not yet issued its final recommendations (see time line below), there are several themes that have emerged from information gathering from stakeholders and from CEUP discussions; these are issues that are likely to impact the committee’s recommendations. CEUP recognizes that changes to the USMLE program can have a major impact on stakeholders and, therefore, it has encouraged the frequent dissemination and discussion of these emerging themes within the stakeholder community. Major themes emerging in this process thus far include the following:

  1. There is a strong sense that the licensure examination program should be more explicitly designed to support decisions at two points. The first of these is a decision about readiness to begin provision of direct patient care under supervision, at the interface between undergraduate and graduate medical education. The second decision relates to readiness for a physician to provide unsupervised patient care and to obtain a license to enter into unrestricted practice.
  2. At the time they enter post graduate training, doctors must have minimum competency in basic clinical knowledge and the skills necessary to safely care for patients. A higher level of these competencies, together with other competencies acquired during graduate medical education, is necessary at the time of primary licensure. To the extent that these competencies can be measured in a valid, reliable, and practical manner, they should be incorporated in the USMLE.
  3. From both a licensing and an educational perspective, the separate design and administration of an examination of the basic sciences seems to create an artificial separation of basic and clinical sciences. This was a sentiment frequently expressed by stakeholders, including faculty members from both the basic sciences and clinical sciences. The weight of opinion gathered to date favors the integration of basic science and clinical science concepts throughout all examination components rather than the current segregation of basic science content in Step 1.
  4. The current Step 1 component of the USMLE is used by many medical schools to support promotion or graduation decisions. If the USMLE is redesigned in a manner that eliminates Step 1 in its current form, then NBME should be prepared to provide similar valid, reliable, and secure assessment tools to schools that still wish to use them.
  5. There are conflicting opinions on the value of numeric versus pass/fail reporting for both the primary and secondary uses of USMLE. It is likely that this issue will not be resolved until the final recommendations of CEUP are made and the implications of those recommendations fully examined.


CEUP has not yet completed its deliberations. It is scheduled to deliver its final recommendations by January 2008. During the remainder of 2008, USMLE committees and staff will identify the implications and feasibility of the recommended changes and the USMLE Composite Committee will make final recommendations to the USMLE parent organizations. The governance bodies of ECFMG, FSMB, and NBME will all have opportunity to review the recommendations in detail. Any major changes to the structure of USMLE require the approval of the FSMB House of Delegates and the NBME membership. The earliest that this full governance review will occur is in the spring 2009. Although it is difficult to predict subsequent time lines prior to receiving the final recommendations, major changes to USMLE design and structure will likely take a minimum of two years, after spring 2009 approval, to implement.