The United States Medical Licensing Examination (USMLE)

The United States Medical Licensing Examination (USMLE) is required to gain a license to practice medicine within the US. It assesses the essential skills for safe and effective patient care and provides a common standard of assessment for medical licensure. This USMLE complete guide will provide all the information you need for applying and undertaking the USMLE, including eligibility, registration and fees, and the different USMLE steps and materials to prepare.

USMLE meaning

The USMLE, or the United States Medical Licensing Examination, simply refers to the examination required to gain medical license within the US. Sponsored by two non-profit organizations – the Federation of State Medical Boards (FSMB) and the National Board of Medical Examiners (NBME) – the USMLE was designed to provide a single national examination to be used by all state medical boards for the medical licensure of allopathic physicians. (Note: COMLEX-USA is used for osteopathic physicians). This ensures that all practising allopathic physicians have met the same assessment standards, regardless of their previous training or which state they practice in.

The USMLE assesses physicians’ ability to apply knowledge, concepts and principles, and evaluates their patient-centered skills. The exam is divided into three multiple-choice tests – Step 1, Step 2 Clinical Knowledge and Step 3 – which are covered in more detail in the USMLE Steps section below.

Who requires the USMLE?

All practicing physicians in an unsupervised setting (i.e. outside of postgraduate training), within the US, require the USMLE. This is because a license to practice medicine is mandatory and the USMLE is an essential requirement for being granted a medical license in the US.

The requirement is the same for graduates who qualified in the US or internationally and ensures that those who trained outside of the US are assessed against the same standards as US medical school students and graduates.

Who is eligible?

To be eligible for the USMLE exam, you must meet the following requirements, both at the time of your application and on the test day:

Step 1 and Step 2 Clinical Knowledge

You must be in one of the following categories:

• A medical student or graduate of a US or Canadian medical school program leading to the MD degree that is accredited by the Liaison Committee on Medical Education (LCME)
• A medical student or graduate of a US medical school leading to the DO degree that is accredited by the Commission on Osteopathic College Accreditation (COCA)
• A medical student or graduate of a medical school outside of the US and Canada, which is listed in the World Directory of Medical Schools as meeting the Educational Commission for Foreign Medical Graduates (ECFMG) eligibility requirements, and who meets other eligibility criteria for the ECFMG.

Note : students must be ‘officially enrolled’; if you are dismissed or withdrawn from medical school, even if you are in the process of appealing, you will not be eligible for the USMLE.

Step 3

To be eligible for Step 3, you must have already successfully completed Step 1 and Step 2 of the USMLE, prior to submitting your application.

You must also hold one of the following:

• The MD or the DO degree from a US or Canadian medical school which is accredited by the LCME or COCA.
• The equivalent of the MD degree from a medical school outside of the US and Canada which is listed in the World Directory of Medical Schools as meeting the ECFMG eligibility requirements. You must also have ECFMG Certification if you qualified outside of the US and Canada.

The USMLE website provides further information on eligibility requirements and attempts and time limits for the exam.

How long is the USMLE?

The length of the USMLE varies across the different 'steps'; the exam length for each is as follows:

• Step 1 : approximately 8 hours
• Step 2 : Clinical Knowledge – approximately 9 hours
• Step 3 : Day 1 – approximately 7 hours, Day 2 – approximately 9 hours

You can find more information about each USMLE step and their format in the section below.

USMLE Steps

The USMLE consists of three multiple-choice tests: Step 1, Step 2 Clinical Knowledge and Step 3. You may also see Step 2 Clinical Skills mentioned in relation to the USMLE; previously, Step 2 included this in addition to the Clinical Knowledge section, however, this has been discontinued.

The USMLE website provides details of the exam format for each section, which are as follows:

USMLE Step 1 Questions

• Length / Time : One-day exam. Seven 60-minute blocks, totaling approximately eight hours including breaks.
• Total number of questions : Approximately 280 multiple choice questions.
• Assessment area : Your ability to apply important, basic science concepts to clinical scenarios, with a focus on the underlying principles and mechanisms of health, disease and modes of therapy.

USMLE Step 2 Clinical Knowledge Questions

• Length / Time : One-day exam. Eight 60-minute blocks, totaling approximately nine hours including breaks.
• Total number of questions : Approximately 318 multiple choice questions.
• Assessment area : Your ability to apply your medical knowledge, skills and understanding of clinical science considered essential for patient care; with a focus on health promotion and disease prevention.

USMLE Step 3 Questions

Step 3 is divided into two parts – Foundations of Independent Practice (FIP) and Advanced Clinical Medicine (ACM) – taken over two days. It assesses your ability to apply medical knowledge and understanding of biomedical and clinical science, with a focus on patient management in ambulatory settings.

Day 1 – FIP:

• Length / Time : One-day exam. Six 60-minute blocks, totaling approximately seven hours including breaks.
• Total number of questions : Approximately 232 multiple choice questions.
• Assessment area : Your knowledge of basic medical and scientific principles essential for effective care.

Day 2 – ACM:

• Length / Time : One-day exam. Six 45-minute blocks (for the multiple choice questions) and thirteen ‘stimulation’ blocks (each given a maximum of 10 or 20 minutes), totaling approximately nine hours including breaks.
• Total number of questions : Approximately 180 multiple choice questions and 13 computer-based case simulations (CCS).
• Assessment area : Your ability to apply your knowledge of health and disease to patient management.

USMLE Timeline

Although there is no strict timeline for undertaking the various stages of the USMLE, there are some restrictions and recommendations that you should consider when planning when to complete each step.

Step 1 and Step 2 can be taken in any order; however, it’s recommended that for students in LCME-accredited medical schools, Step 1 is taken at the end of your second year and Step 2 within your fourth year of study.

You can only take Step 3 of the USMLE once you have successfully completed Step 1 and Step 2. It’s recommended that you should have completed, or be near completion of, at least the first year of postgraduate training in an accredited US graduate medical education program before you undertake Step 3.

The USMLE website also advises that most licensing authorities specify that you must complete Steps 1, 2 and 3 of the USMLE within a seven-year period, starting from when you pass your first step.

Registration

The USMLE Step 1, Step 2 Clinical Knowledge and Step 3 are all computer-based exams administered at Prometric Centers. Note: Step 3 is only administered in the US and its territories. You can find your nearest Prometric Center on their website.

The registration process varies for the different stages of the USMLE and depending on where you study / graduated from. The following are the different registration routes:

Step 1 and Step 2 Clinical Knowledge

• Students / graduates of LCME or COCA accredited medical schools within the US or Canada – apply via the NBME Licensing Examination Services.
• Students / graduates of medical schools outside of the US or Canada – apply via the ECFMG application website.

Step 3

• All medical school graduates (who have passed Step 1 and Step 2) – apply via the FSMB website.

Once you have registered through the appropriate route, the application and scheduling process remains the same for each element of the USMLE and regardless of where you study / graduated from. The steps you need to follow are:

• Select your eligibility period during which you prefer to test.
• Check your emails for your scheduling permit which will be sent to you.
• Visit the Prometric website to schedule your exam.

You can find more information relating to registering and applying for the USMLE on their website.

Total Cost of USMLE Journey for Indian Students: Step-by-Step

Embarking on the United States Medical Licensing Examination (USMLE) journey is a significant commitment, both academically and financially. Understanding the various costs involved is essential for effective planning and budgeting. Below is a detailed breakdown of the expenses you can anticipate:

Updated Examination Fees Table (2025)

Total Examination Fees : $4,900 (₹4.0–4.1 lakh)

Note : The “international surcharge” applies to Step 1 and 2 CK if you choose a testing center outside the U.S. or Canada (which most Indian candidates do). For example, the USMLE Step 1 fee in India is about $1,225 (the $1,020 base fee + $205 surcharge), which is roughly ₹1.02 lakh. All fees are subject to change, so always check the official USMLE/ECFMG website for the latest figures.

• ECFMG Certification Application : A one-time fee to open your ECFMG record (required for all IMGs) – $160.
• USMLE Step 1 and Step 2 CK : Each costs $1,020 (base fee) + surcharge if taken in India. In 2025, that totals $1,225 (≈₹1.02 lakh) for Step 1 and $1,250 (≈₹1.04 lakh) for Step 2 CK.
• ECFMG Pathways & OET : To obtain ECFMG certification (now that Step 2 CS is discontinued), IMGs must apply through an ECFMG Pathways program ($925) and pass an English test. The Occupational English Test (Medicine) costs about $455 (AUD $587) – roughly ₹35,000 – in India.
• USMLE Step 3 : The final exam costs $935 (≈₹78,000). You usually take Step 3 after obtaining ECFMG certification (often during or before residency).

Study Materials and Preparation

Total Study Materials Cost : $1,484 (₹1,22,150) – $3,984 (₹3,29,650)

Totals : Depending on your choices, study materials might cost anywhere from about $1,500 (₹1.2 lakh) for essential books and question banks, up to $3,000–$4,000 (₹2.5–3.3 lakh) if you enroll in premium courses or multiple resources.

United States Clinical Experience (USCE)

Gaining clinical experience in the U.S. is often essential for residency applications and significantly adds to the total cost of USMLE journey.

Total USCE Cost : $2,400 – $7,800 (₹1,99,200 – ₹6,47,300)

Total estimated cost for a 3-month rotation: approximately $9,425 (₹7,81,275).

Residency Application and Match Process

Total Residency Application Cost : Approximately $235 (₹19,505) + additional application fees.

Applying to a higher number of programs increases costs but may improve match chances.

Interview Expenses

Total Interview Cost :  $4,600 (₹3,81,800) for five in-person interviews.

Additional Considerations

• Visa Fees : Costs vary depending on the visa type and processing times.
• Miscellaneous Expenses : Include costs for document translations, mailing, and unforeseen expenses.

Total Estimated Cost of the USMLE Journey:

• Minimum Estimate : $12,644 (₹10,48,855)
• Maximum Estimate : $23,944 (₹19,86,530)

Cost-Saving Tips:

• Early Planning : Schedule exams and applications early to avoid late fees.
• Resource Sharing : Join study groups to share materials and reduce costs.
• Budget Accommodation : Consider cost-effective housing options during rotations and interviews.
• Scholarships and Grants : Research available financial aid opportunities for international medical graduates.

By understanding and anticipating the total cost of USMLE journey, you can create a realistic budget and focus on your preparation without financial surprises. Remember, investing in your medical career is a significant commitment, but with careful planning, it is manageable and worthwhile.