As the only peer-reviewed quarterly publication dedicated to topics and issues critical to medical regulation in the United States and around the world, the Journal of Medical Regulation addresses all aspects of this vital element of public protection. JMR's “Assessment Briefs” offers periodic updates on important information and developments in the examinations relied upon for medical licensure in the United States and globally.
United States Medical Licensing Examination (USMLE)
The United States Medical Licensing Examination® (USMLE®), established in 1991 as a joint program of the Federation of State Medical Boards (FSMB) and NBME, is a three-Step examination for medical licensure in the United States open to students and graduates of schools issuing the MD and DO degrees as well as international schools.
USMLE Service Functions: The USMLE is developing plans to centralize all USMLE service functions. As part of these plans, USMLE services currently provided to international medical students and graduates by ECFMG®, a division of Intealth™, will transition to the USMLE co-sponsors, FSMB and NBME.
This change will consolidate all USMLE examinee services, including exam registration, score report delivery, and USMLE customer service, with the USMLE co-sponsors. The goal of this change is to streamline the examinee journey and to create a more consistent and efficient examinee experience.
The transition of USMLE services is set to take place no earlier than fall 2025. Until then, ECFMG will continue to provide USMLE services to IMGs.
Please note that this change does not affect the requirements for ECFMG Certification. After the transition of services takes effect, ECFMG will continue to determine whether IMGs are eligible for ECFMG Certification, and eligibility for Certification will continue to be a core requirement for IMGs to take USMLE. ECFMG will share information on Certification eligibility with the USMLE co-sponsors for the purposes of registration. Step 1 and Step 2 Clinical Knowledge (CK) will continue to be required by ECFMG to meet the medical science examination requirement for Certification.
Additional information, including more details on the timing of this transition, has been posted at www.usmle.org.
Step 1 Minimum Passing Standard: The USMLE Management Committee voted to maintain the current recommended Step 1 minimum passing standard at its December 2024 meeting.
As part of the USMLE program's operational procedures and in alignment with best practices for licensing and certification exams, a comprehensive review and analysis of the passing standard for each Step exam typically occurs every three years. This process ensures that the passing standard aligns with the expected level of content mastery needed to support effective medical practice and licensure.
In reviewing the Step 1 minimum passing standard, the Committee considered information from multiple sources, including:
Recommendations from independent groups of physicians and educators unaffiliated with the USMLE participating in content-based standard-setting panels in September and October 2024;
Survey results of various groups (eg state licensing representatives, residency program directors, medical school faculty, examinees) concerning the appropriateness of current passing standard for the Step 1 examination;
Data on trends in examinee performance; and
Score precision and its effect on the pass/fail outcome.
As a result of its review, the USMLE Management Committee voted to maintain the current recommended minimum passing standard.
Expiring ECFMG Certificates: The USMLE program requires an unexpired ECFMG certificate to be eligible for USMLE Step 3. Candidates with an ECFMG certificate subject to expiration who wish to take Step 3 must meet these eligibility requirements: (1) Passing scores on Step 1 and Step 2 CK; (2) possess the MD degree, or its equivalent, from a medical school outside the US and Canada that is listed in the World Directory of Medical Schools as meeting ECFMG eligibility requirements; (3) obtain ECFMG certification which is valid and unexpired at the time of application and testing for USMLE; and (4) meet all other eligibility criteria as listed in the USMLE Bulletin of Information.
Examination Integrity: The USMLE program regularly monitors and analyzes examinees’ test performances for unusual score patterns or variations, and other information that could raise questions about the validity of an examinee's results. In late January 2024, the USMLE program announced that it identified a pattern of anomalous exam performance, which challenged the validity of test results for a group of examinees. Highly irregular patterns can be indicative of prior unauthorized access to secure exam content.
Examinees with results in question were notified that their previous Step exams were invalidated and provided an opportunity to take a validating exam in 2024. Most of these individuals opted to do so with validating exam administered in August (Step 1), October (Step 2 CK) or December (Step 3). Where information existed for specific examinees believed to have engaged in irregular behavior, those individuals were referred to the Committee on Individualized Review (CIR). The CIR has adjudicated several dozens of these cases to date.
Comprehensive Osteopathic Medical Licensing Examination of the United States (COMLEX-USA)
The Comprehensive Osteopathic Medical Licensing Examination of the United States (COMLEX-USA) is a three-level, national standardized licensure examination designed for the practice of osteopathic medicine. COMLEX-USA assesses osteopathic medical knowledge, knowledge fluency, clinical skills, and other competencies essential for practice as an osteopathic generalist physician. Passing COMLEX-USA Levels 1 and 2-Cognitive Evaluation (Level 2-CE) is required for graduation from colleges of osteopathic medicine (COMs) with a Doctor of Osteopathic Medicine (DO) degree in the United States.
Continuing the emphasis on candidate wellness demonstrated in the 2022 transition to Pass/Fail score reporting for Level 1, in December 2024 the NBOME Board of Directors approved several enhancements for the COMLEX-USA examination series. For Level 1 and Level 2-CE, the total number of test questions will move from 352 to 320 while continuing eight hours for testing time. These changes are targeted for implementation in the 2026 examination cycles with Level 1 beginning May 2026 and Level 2-CE beginning June 2026. Validity, reliability and fairness of the examinations will be maintained. The Board has also approved transitioning the Level 3 examination from a two-day to a one-day administration starting January 2027. This transition will decrease the burden for residents and graduate medical education programs by minimizing time away from the program for completion of the Level 3 examination. The examination will continue to provide valid, reliable and fair results to state osteopathic medical boards and medical boards for use in licensure for DOs.
The NBOME continues to pilot the Core Competency Capstone for DOs (C3DO), with expansion to eleven COMs at fourteen locations in 2025. C3DO is a standardized assessment of patient-physician communication and interpersonal, history-building, hands-on physical examination, and osteopathic manipulative treatment (OMT) skills in a multistation objective structured clinical encounter model using standardized patients that is developed and scored centrally but delivered at COM campuses. Phase 2 studies in 2024 added evidence for the reliability and validity of the assessment. In the interim, COM deans continue to attest that their graduates have demonstrated the fundamental osteopathic clinical skills necessary for graduation and COMLEX-USA Level 3 eligibility. Currently clinical skills verification remains in place through the graduating class of 2027. The NBOME Board of Directors anticipates making an announcement on the future of this program in July 2025. The requirement of residency program director attestation that each DO resident is in good academic and professional standing for Level 3 eligibility remains in effect.
NBOME continues to ensure that COMLEX-USA adapts to evolving changes in the practice of osteopathic medicine and patient care. The blue-print for the COMLEX-USA examination series is informed by the Fundamental Osteopathic Medical Competency Domains (FOMCD), with its most recent edition published by the NBOME in 2016. In 2024, NBOME began a comprehensive review and revision of the FOMCD to identify and implement enhancements. Our goal is to ensure that competency domains, required elements, and measured objectives remain aligned with best practices for the practice of osteopathic medicine, particularly from a licensure assessment perspective. We anticipate releasing the next edition, “FOMCD 2026,” in early 2026.
The NBOME National Faculty includes practicing osteopathic physicians, residents, educators, researchers, licensing board members, and other assessment and subject matter experts who are critical to our mission of protecting the public. These dedicated individuals create and review test content, participate in standard setting activities, and serve on committees to ensure quality and fairness of our assessments. State licensing board representatives are essential to these activities, as they provide thoughtful and unique perspectives for assessment development and validity activities given the role in medical regulation with osteopathic physician licensure. For more information or to apply, e-mail NBOME National Faculty at [email protected]
