Everything you need to know  about USMLE - basics, best books, cost and a plan for you 

What is USMLE?

 Applying to a residency program in US? Then one of the first things you will need to do is take the USMLE, United States Medical Licensing Examination. To practice medicine in the USA you will have to have completed all the USMLE steps. The USMLE assesses a physician's ability to apply knowledge, concepts, and principles, and to determine fundamental patient-centered skills that constitute the basis of safe and effective patient care.

USMLE is a multi-part professional exam sponsored by the Federation of State Medical Boards (FSMB) and the National Board of Medical Examiners (NBME). Graduates of US and Canadian medical schools accredited by either the Liaison Committee on Medical Education (LCME) or Committee on Accreditation of Canadian Medical Schools, leading to the M.D. (Doctor of Medicine) degree, or by the American Osteopathic Association (AOA), leading to the D.O. (Doctor of Osteopathic Medicine) degree, register for Step 1 and Step 2 of the USMLE with the NBME.

Figure: USMLE - First steps to the residency program

Foreign medical graduates/International medical graduates register for Step 1 and Step 2 with the Educational Commission for Foreign Medical Graduates (ECFMG). All medical graduates local and foreign register for Step 3 with the FSMB or with a medical licensing authority in the United States. 

Note: Before we go any further, please be aware the information below is very subjective and can be completely (vastly) different for each candidate based on several conditions like country of graduation, speed of learning, medical experience, etc.

USMLE Step 1

Step 1 is a computer-based test lasting 8 hours. It consists of (as of 2010) 322 multiple-choice questions divided into seven blocks each consisting of 46 questions. The candidates have one hour for each block plus an hour break. Step 1 is designed to test the knowledge learned during the basic science years of medical school. This includes anatomy, biochemistry, histology, physiology, neuroscience, psychiatry, genetics, pathology, microbiology, pharmacology, molecular biology, immunology and statistics. Epidemiology, medical ethics and questions on empathy are also emphasized. 

Step 1 Scores  - How are mine calculated?

Candidates get a three digit and a double digit score. The three digit score is calculated using a statistical percentile (different from percentage) that ensures that scores from different years are read on a common scale. As of Jan 2010 score of 188 is needed to pass the test, the national mean score is between 200-220, with a standard deviation of around 20. The 2-digit score is derived from the 3-digit score. The 2-digit score is derived in such a way that a score of 75 always corresponds to the minimum passing score. The two-digit score is used to meet requirements of some medical licensing authorities that used a score of 75 as passing. It is by far the most important USMLE step for medical graduates, since some programs decide based only on the Step 1 score.

View real samples of USMLE score report

USMLE Step 2

Step 2 tests your clinical knowledge and skills and how you apply it in the provision of patient care under supervision. It involves two exams - CK aka Clinical Knowledge and CS aka Clinical Skills.

Step 2 CK tests the candidates' clinical knowledge through multiple choice questions. It is a 9 hour exam consisting of 8 blocks of 44 questions each and a one hour break. Questions are based on clinical sciences like Internal Medicine, Surgery, Pediatrics, Psychiatry, Preventive Medicine and Obstetrics & Gynecology. The passing three digit score for Step 2 CK is 184 which correspond to a two-digit score of 75.

Step2 CS tests candidates' clinical skills through mock patient interactions. Specially trained actors mimic symptoms. Candidates face 12 patients (actors). You have 15 minutes to complete history taking and clinical examination for each patient and a further 10 minutes per patient for writing the patient note comprising of the history, examination findings, initial differential diagnosis list and a list of initial tests. You will see 5 patients after which there is a 30 minutes break for lunch followed by 4 cases, then a 15 minute break and then the final 3 cases.  The patient note can by typed on the computer or written on a sheet provided. But, beginning mid-2011, all candidates will be required to type the patient note to a computer and will be allowed to handwrite only if technical difficulties exist at the test centre.

The test is offered only in few cities namely Philadelphia, Chicago, Atlanta, Houston and Los Angeles.

Step 2 CS Scoring: No numerical score, the result is reported as pass/fail.

You are graded in 3 sections which have further sub-sections. It is necessary to pass the individual sub-sections separately. They are as follows:
1. Integrated Clinical Encounter (ICE): This comprises of data gathering (history and examination) and patient note.
2. Communication and Interpersonal skills (ICS) : This comprises of questioning skills, information sharing skills, professional manner and rapport.
3. Spoken English Proficiency.

The patient has a checklist on which he/she grades your performance in all the sub-sections except the patient note which is graded by doctors. The entire clinical encounter is video-taped but these tapes are used only for quality control and not used for grading or rechecks.

Step 2 CS Tips & Tricks

The Step 2 CS might be very tricky, especially for Foreign Medical Graduates.

You go in for your Step 2 CS and the center has created a virtual clinic and actors will present themselves. To err is human and thats what it takes to fail in CS. The error being made by you, the actor or the doctor who evaluates you. Here is what you need to do,

 Be courteous
 Maintain eye contact with the actor/patient
 Be methodical and organized
 Make sure you have asked all the questions required for a specific case
 Be calm; In case you are reminded of a mistake, move on, do not panic.
 In case of doubt, go back and ask the question
 Ask them if they have any questions for you
 Be loud and clear
 Make sure you understand what the patient/actor is saying, if not clarify

The theme is you need to communicate well, which is why it might be a problem for foreign graduates who are non-native English speaker.

Remember "practice makes perfect".

 Practice as many mock examinations for all the cases
 Google for a study partner in the city you are taking CS and practice more
On the day of examination Pray well and wish for all the luck!
Here is a nice thread on How to practice for USMLE step 2 CS.

USMLE Step 3

This is the final step. It tests the graduate in biomedical and clinical science essential for the unsupervised practice of medicine. Step 3 is a sixteen hour exam lasting over two days - eight hours each day. Day 1 has seven blocks of 48 multiple choice questions (total 336). Candidates can take one hour for each block and the extra hour is for the break. Day 2 of testing has four blocks of 36 multiple choice questions (144 in total). Each block should be completed in forty five minutes. Day 2 also includes nine clinical case simulations (CCS). Candidates are required to manage patients in computer based case simulations. Examinees should enter orders for medications and investigations into the computer based software. The computer simulation will dynamically change with the input from candidates. 25 minutes for each case simulation. There is one hour break time on day 2.

Step 3 Tips & Tricks

 All the advice for step 2 applies here too.
 It is recommended not required to take Step 3 before you start the residency. Residents usually take this step during first year and should before the second year.
You will be strapped for Time:
The stress and work load during first year residency is enormous, read this first hand experience by a first year resident, so better to take it before you match.
 The only reason you might want to take step 3 during residency is sometimes the program will pay for the exam
 During match if you have Step 3 you might have higher chances since you will have lesser obstacles during the residency.  Also Step 3 is a must for candidates desiring a H1 Visa.
 The simulations quickly change based on your input, so think quick, practice helps;
 Repeat practice exams. They say 'familiarity breeds contempt', you can have no contempt here, take as many exams as many times you can.

Best Resources

There two types of resources,
1. Books - That provide all the lessons, lectures and knowledge - textbooks.
2. Exam preparatory materials, Questions Banks, Q-Banks - The computer software that provide exam like multiple choice questions that you can be tested on. The resources below are only exam preparatory materials and not text books. It might not be sufficient to read only these books below, for a much stronger foundation you will need to spend more time reading them first. Below we discuss some of the best preparatory materials that are out there. For each his/her own so see what suits you and choose wisely.

Step 1

	First Aid for the USMLE Step 1, 2010 Edition - Pros & Cons This book has been there around for almost 2 decades. It is like the bible of step1. Pros,  Unique approach using more figures, charts and factoids than text.  Has test-taking advice from latest residents about their experience.  Gives you strategies to remember key points .  Has a rapid review section for last minute quick review. Cons,  The indexing for some items (drugs, etc) are not done right . This can make it frustrating and time consuming to find what you are looking for. It serves as a complete guide and hence takes time.  Should never be used as the primary book.
	Kaplan USMLE Step 1 Home Study Program By far the most commonly used notes there is for USMLE Step 1. Kaplan is also a trusted name in educational software area. It has 4 volumes, two general principles books reinforce your learning of basic concepts, whereas our two organ system books examine each organ system through the lens of disciplines embryology, histology, anatomy, physiology, pathology, and pharmacology. It also comes as audio book and video lectures. I you like to listen to them rather than read a book, this is for you. Pros, Covers every topic in depth  Each volume contains helpful margin notes, clinical correlates, bridges to other topics, tables, illustrations, mnemonics, and conceptual summaries. Cons,  The volumes are very extensive.  The one topic not covered very well (as of 2010) Pathology. It is recommended to read another book Rapid Review Pathology by Edward F. Goljan.  Expensive. Kaplan QBank Good questions, very exam like but many prefer the USMLE World.
USMLEWorld.com Step 1 Online Testing System - Pros & Cons Website that provides question bank and review material. Q-bank should be solved prior to the exam, since it a good indicator of the level of preparedness before the exam. Questions are very good. Widely preferred and recommended. Pros,  This is a great online resource, so all you need is a modern web browser and you are ready to go   Very comprehensive question bank, updated regularly.   Questions are more difficult than the actual USMLE, which is good  Each question has a full explanation with illustration and table. Cons,  Only thing we can think of is the prices have gone up steeply.
USMLE Official test preparation content They provide the content that will be covered in the test and also some free software Fred VX Step1 for practice.  Tutorial and Practice Test Items for Multiple Choice Questions - USMLE Official website

Step 2 & 3

	Current Medical Diagnosis & Treatment One of the best books for all medical graduates and residents. It is a keeper, can be very helpful even after you complete your residency. Some call it the bible for medical residents. Pros,  Combination of practical information and theoretical details  Updated frequently and each update makes the book much more valuable. Cons, Nothing really.
	Swanson Family Practice Review: A Problem-Oriented Approach,5th Edition One of the best books not just for steps but for any medical graduate. Since the original author is no more, the book has not been updated frequently. Pros,  It uses a case-oriented approach.  Has in-depth coverage of every clinical specialty.  Everything in this book is explained in a step by step manner, text is easy & logical.  Each chapter has a quick summary at the end. Cons,  The last edition was in 2004, a lot of information is out dated and several references are from 80's & 90's hence you need to keep up with the latest medical trends & treatment.  This book takes time and is not something for a last minute cram.
	USMLE Step 2 Secrets There are medical books that should be saved for life and then there are books custom made for reading right before the exam. This is it. An excellent cram book. Pros,  Very concise.  Might be the only review book you need.  Very light read.  Well organized. Cons,  Crush Step 2: The Ultimate USMLE Step 2 Review has very similar content. Candidates prefer the USMLE Step 2 Secrets since the same content is much more organized and layed out beautifully. Crush Step 2 is not very well organized and also very light on information. Step 2 secrets is much preferred to Crush Step2.
	Deja Review USMLE Step 2 CK Yet another book that is high-yield & quick hit. Has questions and answers about the most relevant and commonly tested topics. Pros,  This book is so concise and there are candidates who have read it in 3 days flat.  Very inexpensive.  Well-organized.  Great for quizzing yourself and pinpointing your weaknesses & strengths. Cons,  Not for reference, only for last minute cramming.  There are a few errors and inaccuracies are a little difficult to spot when the answers are unexplained and concise.
	Nail the Boards 2007-2008! The Ultimate Internal Medicine Review for USMLE Steps 2 & 3 Pros,  The exam questions are very close to the book.  The use of mnemonics, underlining, bolds, italics, boxed-in points, and bullets clearly drew attention to the most important points for the exam.  Excellent indexing.  It is required reading in several residency programs.  Time saver.  Gives you good memory aids to remember key concepts. Cons, A little pricey than other book but worth every cent. One of the best books out there and candidates using it have scored very high.

Cost of all three steps

The cost of all three USMLE steps are very subjective. The estimate below is based on several assumption and might vary for each candidate. The books, Q-banks, online tests, etc used by each individual might be different and hence the cost will also be different. It is recommended you do your own research and come up with more accurate total.

ITEM	COST ($)
Step1
Resources     - Books, Q-Banks, Online subscriptions	500
Exam Registration	525 (940 for FMG)
Travel (domestic)	150 (approx)
Accommodation (per night)	100
Total	1275 (1690 for FMG)
Step2
CK
Resources     - Books, Q-Banks, Online subscriptions	500
Exam Registration	525 (940 for FMG)
Travel	150 (approx)
Accommodation	100
Total	1275 (1690 for FMG)
CS
Resources     - Books, Q-Banks, Online subscriptions	100
Exam Registration	1120
Travel  *	1800
Accommodation *	300
Total	3540
Step3
Resources     - Books, Q-Banks, Online subscriptions	700
Exam Registration	700
Travel *	1800
Accommodation *	300
Total	3500
GRAND TOTAL	9505 (10375 for FMG)

^* FMGs are required to travel to US to take the Step 2 CS, so if you are a FMG then your air fares will differ based on where you live and fly to US from. If you are local in US then your airfare will be around 150-250.

^* Staying in share accommodation, that charges $20 per day per person. Assumes you stay for 15 days for practicing CS with study partners for 15 days.The cost of resources is also assumed and could be a combination of any books, q-banks and tests.
The fees are subject to change, please check the rates from the official sites.

How long does it take to prepare?

The schedule for taking these exams is very subjective. It depends on factors like how many trext books you read and also if you are working when you take your USMLE. The time line below assumes you do not work and also does not include the time spent reading text books but only USMLE focused preparatory books,

Resources	Time (in days)
Step 1
Kaplan Notes USMLE World	120 45
Step 2 CK
Kaplan Notes USMLE World	75 45
Step 2 CS
Mock Practice	20-30
Step 3
Kaplan Notes USMLE World	60 45

Note: Many candidates do not feel confident after reading only Kaplan notes as it is concise and read other books especially from the recommended list above. Candidates also practice longer using USMLE World.

A plan for you

Considering the above conditions you need to give the steps before the periods mentioned below:

It is assumed that the candidate clears the exams in their first attempt (which might not be the case). If you fail one of your exams, the time line will change.

Finally

If you reached this far, congratulations! You just completed the guide to USMLE. Now get back to studying.