The Comprehensive USMLE Guide For Pakistani Medical Students (Part 1: USMLE - An Introduction)

USMLE stands for United States Medical Licensing Examination. In order to practice in the U.S., all medical students whether IMGs (international medical graduates) or AMGs (American Medical Graduates) have to give this series of exams.

Only then does an international medical graduate become ECFMG certified and legally allowed to practice in the United States. (ECFMG stands for educational commission for foreign medical students. ECFMG acts as the registration and score-reporting agency for the USMLE for foreign medical students/graduates, or in short, it acts as the designated Dean's office for International Medical Graduates in contrast to the American Medical Graduates).

It conducts three examinations: Step 1, Step 2CK, Step 2CS. The ECFMG certificate is issued to a physician if he or she passes the above the three exams within a time period of seven years.)

The Following elements are essential in order to secure a residency in the US:

1. Scores

1. Step 1
2. Step 2 : i) Step 2 CS, ii) Step 2 CK
3. Step 3  

2. U.S.C.E (US clinical experience)
3. Letters of Recommendations (LORs) from US physicians

In addition to this:

1. 1. Personal Statement
2. 2. Medical School Transcript/Result
3. 3. CV (Extra-circulars)

SCORES This is the single most important criteria. But only scores even exceptional won’t help get a residency. You can have 260s in both Steps and Pass the clinical portion in first attempt but if you don’t have electives or LORs then you might as well not apply.

USMLE is divided into THREE Steps:

STEP 1: It tests the basic sciences. It covers all the subjects taught in our Med-Schools till 4th year except Forensics.

It is a Computer based Multiple Choice Question exam. Step 1 is a one day examination. It is divided into seven 60-minute blocks and administered in one 8-hour testing session. The number of questions per block on a given examination form will vary, but will not exceed 40. The total number of items on the overall examination form will not exceed 280. There is no negative marking.

This USMLE test is offered twice a week (Wed+Thurs) all year except from 1st to 15th Jan.

For Step 1, the fees is US $895. In addition the ECFMG registration fee is $75.

STEP 2: This part is further divided into two parts: the Clinical Skills part  (Step 2 CS) and the Clinical Knowledge part (Step 2 CK).

Step 2 CK is just like Step 1 but it assesses your command on the subjects taught in Final year of our Med-School.

Step 2 CS uses standardized patients to test medical students and graduates on their ability to gather information from patients, perform physical examinations, and communicate their findings to patients and colleagues.

This exam can only be given in the United States. You’ll have to go to America to actually give this part of Step 2. The result is either Pass or Fail in this component of Step 2.

All applicants have already given these exams before applying for the Match.

STEP 3: Most medical graduates give this part of MLE after they’ve gotten residency. It’s not considered essential when you apply for the match. But now-a-days due to severe competition Medical Graduates have starting giving it before the match to make their applications stronger.

U.S.C.E (US Clinical Experience): After scores, this is the most important criteria. I’ll emphasize again that scores without USCE won’t do anything for your application.

USCE basically means rotations in US hospitals for a specific time to get hands-on experience working in a US hospital. USCE includes two types: Electives and Observerships.

Ideally around 4 months USCE would be preferred (in 3-4 different hospitals). You learn a lot during this period. Electives (A type of USCE) also result in your procuring Letters of Recommendations from your attending physician. 4 LORs are required. However, you are only eligible for electives only till you are a medical student; as soon as you graduate, you won’t be eligible for them.

Most IMGs (international medical graduates) go to America after giving their final professional exam. They do USCEs in the time between their last exam and graduation. This hands-on experience also prepares them for Step 2 CS.  So they give the Clinical Skills component of STEP 2 during their stay in America usually between USCEs.

Electives done in Pakistan hold no value at all for your MLE application. Some IMGs prepare for and give MLE after their house job, they won’t be eligible for electives (a type of USCE)  but they can do observerships. Your experience needs to be in the speciality you plan on applying to. Apply for USCEs at least 6 months before: it’s a long process and it takes time.

For more information, keep a lookout for another detailed article on USCE in these series of guides.

L.O.Rs: As mentioned earlier, letters of recommendations (L.O.Rs) need to be from American physicians. You can get them while you’re doing electives in the US. Again scores and electives without LORs aren’t sufficient. The program directors need to know that, despite the fact that you have the required scores, if you be able to work in an American hospital. And if even you can work, can you excel at it? Can you interact in a healthy manner with your team members? L.O.Rs serve this purpose. They are basically letters from US physicians who’ve worked with you and deemed you capable of functioning efficiently in a US hospital. Hence they’re recommending you for the position you’re applying to. These L.O.Rs should be from be from physicians working in the speciality you’ve applied to.

For more information, keep a lookout for another detailed article on L.O.Rs in these series of guides.

Research: Research is an important component but it isn’t essential. Of course if you have research publications or even research experience than this will make your application stronger; however, you can still get a residency even if you don’t.

The thing is IMGs (international medical graduates) don’t apply to and are not usually accepted to university programs. There are different types of residency programs University programs, community programs and accredited /non accredited programs. (For further information, refer to the article discussing the differences between these types).

Community programs aren’t focused on research so they won’t bother you about it.

However if you’re still interested in research than you need to do a proper one and try to get it published in one of the internationally acclaimed journals like pubmed etc. Otherwise your research won’t really do anything for your application. Another thing you can do is try to get research electives with a US doctor. You’ll have to go to university sites, find the doctor and email him mentioning the research work he’s doing and why you’re interested in it. Youll have to send 100s of emails and patiently wait. It would do you good if you add your personal statement, your CV etc. If you get an invite from any of the recipients of your email then you’ll have to go to the US and do electives (1month to 6 months) depending on the time you have. However if your internship is only of 1 month it won’t really be fruitful but it will still be a great learning experience for you plus you’ll be making contacts. Believe me contacts really matter.

For more information, keep a lookout for another detailed article on this topic in these series of guides.