USMLE Step 2 CK Facts
When should I take Step 2?
Many U.S. medical schools now require a passing score on the USMLE Step 2 examination
before graduation. It is also recommended that students take the exam after finishing
all basic clinical clerkships. When the test was hand-written (pre-2000), it was
only offered twice annually, but now that the exam is computerized students can
essentially take it anytime during their fourth year. With regards to the application
process, taking the examination early in fourth year typically makes the results
available to program directors whereas taking the examination later means that the
score will not be factored into the residency selection process. Students disappointed
in their Step 1 score may opt to take the test earlier in hopes of achieving a more
impressive score for residency selection committees to consider.
A 2004 study looked at the relationship between the timing of when students took
the exam and their eventual score. Students who took the examination in June through
August of fourth year tended to score better than they had on Step 1, whereas students
who took the exam in spring of fourth year tended to do worse than they had on Step
I. This may reflect better recall of clerkship knowledge when taking the exam earlier,
as well as stronger motivation to perform well when taking the test at a time that
would make the results available to residency selection committees. While it seems
that for most students, the primary consideration in timing Step 2 is strategy with
regards to residency application, students who feel they may be at risk of failing
the exam may benefit from taking the test earlier in the fourth year so that key
clinical information is fresher in their minds.
Pohl CA, Robeson MR,
Veloski J. USMLE Step 2 Performance and Test Administration Date in the Fourth Year
of Medical School. Academic Medicine, 79(10), October Supplement 2004, S49-S51.
Why is Step 2 important?
With the extreme focus placed on USMLE Step 1 both by program directors and medical
students, many may overlook Step 2 and perhaps invest considerably less effort preparing
for this exam. However, as the material on Step 2 is more clinically relevant and
patient centered than on Step 1, the material studied and tested is likely to be
more relevant to students in their future careers. Though there is evidence that
much of the material tested by Step 1 may not be retained as students progress in
their careers, one would hope that the more clinically relevant material of Step
2 might be retained better in the long run (see "How much basic science material from USMLE Step 1 will I end up
remembering in the long term?").
In addition to its educational value, Step 2 has also been shown to be an important
factor in the residency selection process. A 2006 survey issued to program directors
nationwide determined that Step 2 CK and CS are the fifth and sixth most important
factors, respectively, in resident selection (notably ranking higher than AOA status,
research experience, class rank, and medical school reputation). Step 1 scores were
considered the second most important factor. (There was some variation with respect
to Step 2 importance between specialties, with program directors from fields considered
'less competitive' giving more weight to Step 2 CK and CS scores than program directors
from more competitive specialties.) Given their importance, fourth year students
should strongly consider taking these tests early enough in the application process
to allow the results to be available to residency program directors.
Green M, Jones P,
Thomas, JX. Selection Criteria for Residency: Results of a National Program Directors
Survey. Academic Medicine 84(3), March 2009, pp 362-367.
Is the Step 1 score predictive of the Step 2 score?
While the USMLE Step 1 and 2 exams cover different material, basic sciences and
clinical knowledge respectively, there are similarities between the tests as they
are both written by the same governing body. A study of USMLE performance in the
mid 1990s (when the exam was converted from the NBME to the USMLE exams) showed
a strong correlation between Step 1 and 2 performance. A more recent study in 2006
similarly showed correlated results.
Interestingly, the correlation was stronger for students from medical schools with
a higher average USMLE Step 1 score; this may be reflective of an environment that
encourages strong study habits and drive to achieve. The correlation was also stronger
at larger medical schools, possibly because some smaller schools have a more narrow
curricular focus or less diverse patient population.
Multiple studies have also demonstrated a difference in performance on the tests
based on gender. While the overall pass rates between genders are similar, studies
have demonstrated that male students generally outperform females on Step 1 while
females perform equal to or better than males on Step 2 CK. While controversial,
some believe this may be in part because female students may have less of a basic
science background upon entering medical school leading to lower Step 1 scores while
Step 2 CK includes areas which have traditionally been of more interest to female
students, such as pediatrics, psychiatry, and obstetrics/gynecology, in turn leading
to higher scores. Overall, there was a stronger correlation of Step 1 with Step
2 performance in males than females.
Cuddy MM, Swanson
DB, Dillon GF, Holtman MC, Clauser BE. A Multilevel Analysis of the Relationships
Between Selected Examinee Characteristics and United States Medical Licensing Examination
Step 2 Clinical Knowledge Performance: Revisiting Old Findings and Asking New Questions.
Academic Medicine 81(10), October 2006 Supplement, S103-S107.
Case SM, Swanson DB,
Ripkey DR, Bowles LT, Melnick DE. Performance of the Class of 1994 in the new era
of the USMLE. Academic Medicine 71 (10), October supplement 1996, S91-S93.
Is there a correlation between performance on USMLE exams and specialty board licensing
exams later in training?
Residency programs weigh USMLE performance heavily in the resident selection process.
One often-cited justification for this is that students who perform well on the
USMLE likely have the skills to perform well on board certifying exams too. This
is important, as poor resident performance on board certifying exams reflects poorly
on the residency program.
A 2009 study examined the relationship between USMLE performance and resident performance
on the internal medicine in-training examination. While the in-training examination
is not directly involved in board certification for internal medicine, performance
on the test has been independently correlated with performance on the certifying
exam. The study demonstrated that there was a positive correlation between USMLE
scores and performance on the in-training exam. Of Step 1, Step 2, and Step 3, the
correlation was strongest by far for the USMLE Step 2. It seems this correlation
holds even for specialty fields; a 2006 study examined the relationship between
performance on USMLE Steps 1 and 2 with performance on the orthopedic surgery in-service
training exam and found similar results (specifically, a positive correlation between
scores on USMLE Step 2 and on the in-service training exam, but no significant correlation
with Step 1 scores). Overall, these results suggest that performance on USMLE tests
may indicate future success on board certification exams whether the student chooses
a broad or narrow specialty, with the Step 2 exam likely having the closest correlation.
Perez JA, Greer S.
Correlation of United States Medical Licensing Examination and Internal Medicine
In-Training Examination performance. Adv in Health Sci Educ (2009) 14:753–758.
Black KP, Abzug JM,
Chinchilli VM. Orthopedic In-Training Examination Scores: A Correlation with USMLE
Results. Journal of Bone and Joint Surgery. 88A(3), March 2006, 671-676.
Which aspects of my clinical training will most impact my score on the USMLE Step
Clinical clerkships vary widely at different medical schools. Even students from
within the same medical school may have quite different clerkship experiences. A
2009 study attempted to quantify the effect that different variables pertaining
to clinical clerkships have on USMLE Step 2 performance. The most significant factor
appeared to be the number of patients cared for in a day. Students who had a significant
improvement in their Step 2 score over their Step 1 score saw significantly more
patients per day. Students who had a significant drop in score cared for significantly
fewer patients per day. However, the study did not examine the effect of the precise
number of patients cared for. One might expect an eventual threshold effect, beyond
which increased patient load brought diminishing returns secondary to students becoming
Among students with high Step 1 scores, those with better Step 2 scores tended to
have more exposure to hospitalists, higher NBME shelf exam scores, and longer attending
rounds. In contrast, for students with lower Step 1 scores, more structured learning
formats such as small groups, computer-based instruction, and separate rounds with
a teaching attending seemed to have more benefit for the Step 2 score. Both groups
of students tended to do better on Step 2 with 4 week rather than 2 week clinical
clerkships. These results suggest that some curriculum reforms may not benefit all
Griffith CH, Wilson
JF, Haist SA, Albritton TA, Bognar BA, Cohen SJ, Hoesley CJ, Fagan MJ, Ferenchick
GS, Pryor OW, Friedman E, Harrell HE, Hemmer PA, Houghton BL, Kovach R, Lambert
D, Loftus TH, Painter TD, Udden MM, Watkins RS, Wong RY. Internal Medicine Clerkship
Characteristics Associated with Enhanced Student Examination Performance. Academic
Medicine 84(7), July 2009, 895-901.