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Step 1

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Step 1 includes test items in the following content areas:

• anatomy,
• behavioral sciences,
• biochemistry,
• microbiology,
• pathology,
• pharmacology,
• physiology,
• interdisciplinary topics, such as nutrition, genetics, and aging.

Step 1 is a broadly based, integrated examination. Test items commonly require you to perform one or more of the following tasks:

• interpret graphic and tabular material,
• identify gross and microscopic pathologic and normal specimens,
• apply basic science knowledge to clinical problems.

Step 1 classifies test items along two dimensions: system and process, as shown in Step 1 Specifications.

Continue to: Step 2 Clinical Knowledge (CK) »

Step 2 Clinical Knowledge (CK)

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Step 2 CK includes test items in the following content areas:

• internal medicine,
• obstetrics and gynecology,
• pediatrics,
• preventive medicine,
• psychiatry,
• surgery,
• other areas relevant to provision of care under supervision.

Most Step 2 CK test items describe clinical situations and require that you provide one or more of the following:

• diagnosis,
• a prognosis,
• an indication of underlying mechanisms of disease,
• the next step in medical care, including preventive measures.

Step 2 CK is a broadly based, integrated examination. It frequently requires interpretation of tables and laboratory data, imaging studies, photographs of gross and microscopic pathologic specimens, and results of other diagnostic studies. Step 2 CK classifies test items along two dimensions: disease category and physician task, as shown under Step 2 CK Specifications.

Please note that much of the content that addresses normal growth and development and general principles of care is also related to the individual organ systems categories, so that the number of questions that deal solely with normal growth and development and general principles of care is relatively small

Continue to: Step 2 Clinical Skills (CS) »

Step 2 Clinical Skills (CS)

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Step 2 CS assesses whether you can demonstrate the fundamental clinical skills essential for safe and effective patient care under supervision. There are three subcomponents of Step 2 CS (see Subcomponents of Step 2 CS): Integrated Clinical Encounter (ICE), Communication and Interpersonal Skills (CIS), and Spoken English Proficiency (SEP).

Step 2 CS uses standardized patients, i.e., people trained to portray real patients. You are expected to treat the standardized patient as a “real” patient, and accomplish all elements of a physician/patient encounter, assuming responsibility for the immediate post-visit needs of the patient, with the expectation that you may see the patient again. This means you should not defer decision-making to others (such as a supervising physician).

The elements of the history and physical examination necessary for each case will be determined by the nature of the patient's problems. The cases you will see will not require you to do a complete history and a complete physical examination. In fact, if you attempt to do so, you may run out of time, and will not be able to fully address the emotional and communication needs of the patient.

You will be expected to communicate with the standardized patients in a professional and empathetic manner. As you would when encountering real patients, you should answer any questions they may have, tell them what diagnoses you are considering, and advise them on what tests and studies you will order to clarify their diagnoses.

After each interaction with a patient, you will complete a patient note. You will record pertinent history and physical examination findings, list diagnostic impressions, and outline plans for further evaluation, if necessary.

The cases cover common and important situations that a physician is likely to encounter in common medical practice in clinics, doctors’ offices, emergency departments, and hospital settings in the United States. The cases that make up each administration of the Step 2 CS examination are based upon an examination blueprint. An examination blueprint defines the requirements for each examination, regardless of where and when it is administered. The sample of cases selected for each examination reflects a balance of cases that is fair and equitable across all examinees. While the set of cases administered on a given day will differ from the set of cases administered on another day, each set of cases is comparable.

The intent is to ensure that examinees encounter a broad spectrum of cases reflecting common and important symptoms and diagnoses. The criteria that are used to define the blueprint and create individual examinations focus primarily on presenting complaints and conditions. Presentation categories include, but are not limited to, cardiovascular, constitutional, gastrointestinal, genitourinary, musculoskeletal, neurological, psychiatric, respiratory, and women's health. Examinees will see cases from some, but not all, of these categories. The selection of cases is also guided by specifications relating to acuity, age, gender, and type of physical findings presented in each case.

Planned Enhancements to Step 2 CS

In 2010, pilot tests of changes to communication skills assessment and changes to the patient note were successful, with further testing planned for the second half of 2011. If further testing in 2011 is also successful, changes will be implemented in the Step 2 CS examination in mid-2012. Confirmation of any change will be posted to the USMLE website sometime after November 2011.

Potential changes to the patient note include asking examinees to document their analysis of a patient’s possible diagnoses, citing the evidence obtained from the history and physical examination that supports (or refutes) different diagnostic possibilities.

Changes to communication skills assessment are targeted to enhance the nature and difficulty of challenges posed by the standardized patient (SP). Examinees will be assessed based on their ability to tailor their questions and responses to the specific needs of the case presented and on their ability to react to the entire range of the patient’s concerns, thus mirroring desirable physician behaviors. More information about the enhancements to the assessment of communication skills is available in the Fall/Winter 2010 NBME Examiner, available on the Publications page of the NBME website, www.nbme.org.

Continue to: Step 3 »

Step 3

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Step 3 is organized along two principal dimensions: clinical encounter frame and physician task (see Step 3 Specifications). Step 3 content reflects a data-based model of generalist medical practice in the United States.

Encounter frames capture the essential features of circumstances surrounding physicians' clinical activity with patients. They range from encounters with patients seen for the first time for nonemergency problems, to encounters with regular patients seen in the context of continued care, to patient encounters in (life-threatening) emergency situations. Encounters occur in clinics, offices, skilled nursing care facilities, hospitals, emergency departments, and on the telephone. Each test item in an encounter frame also represents one of the six physician tasks. For example, initial care encounters emphasize taking a history and performing a physical examination. In contrast, continued care encounters emphasize decisions regarding prognosis and management.

High-frequency, high-impact diseases also have an effect on how the content of Step 3 is organized. Clinician experts assign clinical problems related to these diseases to individual clinical encounter frames to represent their occurrence in generalist practice.

Primum® Computer-Based Case Simulations (CCS)

Step 3 examinees test using two formats: multiple choice questions and Primum computer-based case simulations (CCS), a testing format that allows you to provide care for a simulated patient. You decide which diagnostic information to obtain and how to treat and monitor the patient's progress. The computer records each step you take in caring for the patient and scores your overall performance. This format permits assessment of clinical decision-making skills in a more realistic and integrated manner than other available formats.

In Primum CCS, you may request information from the history and physical examination; order laboratory studies, procedures, and consultants; and start medications and other therapies. Any of the thousands of possible entries that you type on the "order sheet" are processed and verified by the "clerk." When you have confirmed that there is nothing further you wish to do, you decide when to reevaluate the patient by advancing simulated time. As time passes, the patient's condition changes based on the underlying problem and your interventions; results of tests are reported, and results of interventions must be monitored. You suspend the movement of simulated time as you consider next steps. While you cannot go back in time, you can change your orders to reflect your updated management plan.

The patient's chart contains, in addition to the order sheet, the reports resulting from your orders. By selecting the appropriate chart tabs, you can review vital signs, progress notes, patient updates, and test results. You may care for and move the patient among the office, home, emergency department, intensive care unit, and hospital ward.

The cases used in the CCS portion of the Step 3 examination are based upon a CCS examination blueprint. The blueprint defines the requirements for CCS examination forms. The CCS blueprint is used to construct CCS examination forms focusing primarily on presenting symptoms and presenting locations. Presenting symptoms relate to the Step 3 Problem/Disease List and are associated with the central nervous system, eye/ear/nose/mouth/throat, respiratory system, circulatory system, digestive system, behavioral/emotional disorders, musculoskeletal system, skin/subcutaneous tissue, endocrine/nutrition/ metabolic disorders, kidneys/urinary tract, reproductive system, pregnancy/childbirth, neonate/childhood illnesses, blood and blood-forming organs, infectious/parasitic diseases, injuries/wound/toxic effects/burns, and health maintenance issues. Presenting locations include the outpatient office, emergency department, inpatient unit, intensive care unit, and the patient's home.

You will see cases related to some, but not all, of these problem/disease and location categories. The intent is to ensure that all examinees encounter a broad range of cases reflecting common and important symptoms and diagnoses. The selection of cases is also guided by specifications relating to age and gender. Each CCS examination form is structured to reflect a balance of cases that is fair and equitable for all examinees.