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Pathway From USMLE Step 1 To Residency – Everything You Need To Know

USMLE stands for United States Medical Licensing Exams. It is mandatory for anyone who wishes to get into residency and practice in the U.S to take these exams.

This post will give you a run through the whole process from the USMLE to the residency match.


Overview of The Process

The whole process starts with two main exams, Step 1 and Step 2 CK. There is a third exam, Step 3, which is not a mandatory exam to get you into residency. Most people end up taking Step 3 after they get into residency.

The Occupational English Test (OET) is another important exam. It is actually a replacement for Step 2 CS and is taken to test your English.

Once you have taken your Step 1, Step 2 CK, and OET, you get ECFMG certification. With the ECFMG certification, you can apply for the NRMP match. Applicants apply to match to different programs they want to get in and the programs will check their applications and if they like the person’s application and the scores they’ll send them an interview. That’s basically the NRMP match.

After the interview, the rank order list follows next. This is where programs and applicants rank each other. The match date then comes after. The NRMP declares people who have matched or people who have not matched and then once you’re matched, you get into residency.

USMLE Step 1

The whole process of USMLE starts with the ECFMG registration. ECFMG stands for Educational Council for Foreign Medical Graduates. This council allows international medical graduates to participate in the match process and practice medicine in the U.S. You have to get registered and fill out the Certification Statement called form 183. Once you fill the form 183, you’ll be eligible to write USMLE Step 1.

USMLE Step 1 used to be scored, a three-digit numerical score was usually released after taking the exam. However, from January 26, 2022, it was changed to a PASS/FAIL system. The minimum passing score was also changed from 194 to 196.

How Much Time Do You Need To Prepare for USMLE Step 1?

The average time needed to prepare for your USMLE Step 1 is between five to seven months. This may be longer depending on your schedule.

USMLE Step 1 Questions

Step 1 tests your pre-clinical knowledge, that is your basic sciences right from your first and second year of medical school. The exam is about eight hours long and it is divided into seven blocks.

One block lasts for an hour and contains 40 questions. This brings the total number of questions in Step 1 to about 280 questions. There is also a one-hour time period which is divided into a 15-minute orientation and a 45-minute break. This 15-minute orientation can actually be done before doing the exam through the NBME website. If you do this, you can convert the 15 minutes for orientation into your break time, and then you can get like about a one-hour break time.

Study Resources You Need To Prepare for USMLE Step 1

These are the resources you need for your USMLE Step 1 preparation.

  • Boards and Beyond
  • UWorld
  • First Aid
  • Pathoma
  • Sketchy


USMLE Step 2 CK basically tests your clinical knowledge. It tests how you can apply your basic clinical knowledge of medicine, ob-gyn, pediatrics, and surgery. A lot of Step 1 questions may also pop up.

This is likely going to be the new “Step 1” as the scoring system is still numerical. Program directors require a numerical score or data to somehow screen through many applicants and with Step 2 CK still remaining a three-digit score, this is the most probable option.

USMLE Step 2 CK Preparation and Questions

An average of 4 to 5 months is required to prepare for Step 2 CK. The exam is nine hours long with eight blocks, each block lasting for a duration of one hour. There are about 40 questions in each block, bringing the total number of questions to 320 questions.

There is also a one-hour break which is divided into a 15-minute orientation and a 45-minute break. You can again do the orientation before you go to the exam so you can convert that into your break and have a one-hour break.

Study Resources You Need To Prepare for USMLE Step 2 CK

  • UWorld
  • Boards and Beyond
  • Divine Intervention Podcast
  • Amboss Library

Occupational English Test (OET)

As mentioned earlier, this is a replacement for Step 2 CS which was recently discontinued because of the big problem of covid.

Preparing for OET does not require a lot of time. The resources that you will need include:

  • E2 OET Free Course
  • Official OET Sample Papers

You can search up E2 OET on YouTube. They have a big youtube channel and a free course that can help you orient yourself for the whole exam. The Official OET sample papers are useful for reading, writing, listening, and speaking. After this, you can apply for the ECFMG certification.

ECFMG Certification

The ECFMG certification shows that you have been certified to be of good clinical training as an American medical graduate. To apply for ECFMG certification you need your USMLE Step 1 and Step scores, your medical degree, and a letter of good standing from your university. Once you have all these, you can apply for ECFMG certification and then you can apply for the match.

One thing that you need to understand is you don’t especially require ECFMG certification to apply for the match but it is highly recommended because a lot of programs make ECFMG certification a requirement, without which they would not take your application.

The NRMP Match

Once you get ECFMG certified, the NRMP match starts. The NRMP match as already stated earlier is where programs, as well as applicants, participate. You as an applicant will submit an ERAS application where you’ll have your professional experiences, volunteer experiences, research experiences, personal statement, letters of recommendation, MSPE, and medical transcripts. The ERAS application or CV will be presented to the programs that you’ve applied for an interview. If a program likes your ERAS application, you will be sent an interview.

What is included in the ERAS Application?

The ERAS application includes professional experiences, volunteer experiences, and research experiences. This is basically your experiences in the field of medicine and outside medicine.

Professional experiences are divided into two things;

  • United States clinical experience –  this is the most important because programs want to know what you know about the U.S medical system. They want to know if you have lived in the U.S medical system if you have seen how it is and if you are oriented to it.
  • Professional experiences in your home country – this includes internships, job experiences, or residency training.

Volunteer experience is anything that you did voluntarily and without being paid.

Research experiences are any experience where you have worked with a team that was dedicated to research. This does not include individual research. Being interested in research is awesome, learning these skills is very handy for the programs and this would just boost up your cv even more and make you even more attractive in the whole match. Research experience is also very important for competitive programs such as surgery, dermatology, radiology, or orthopedics.

The ERAS application also contains a personal statement, which basically states the reason why you want to get into a certain specialty. It also includes your aspirations.

Letters of recommendation (LORS) are divided into LORS from the U.S and LORS from your home country. LORS are written by professors or attendings who are practicing medicine in any country, either in the U.S or your home country. They serve as a testament to your qualities as a physician. Like how good you are in communication and your cultural values professionally.

U.S LORS are more valued than home country LORS. This is because U.S physicians know the U.S system better and they can assess you and your qualities in the context of U.S healthcare. It serves as a stamp of approval on you.

You can upload a maximum of four LORS per program. A lot of people just upload about two or three LORS from the U.S and one LOR from their home country.

There is also the Medical School Performance Evaluation (MSPE). This shows how your school evaluates you in character, knowledge of basic sciences, and clinicals. It also shows how you performed in your rotations. It is basically your evaluation compared to your peers in your medical school and shows if you are in the top 25 percent or on the dean’s list. The medical school transcripts are basically your performance in different clinical examinations.


After submitting your ERAS application, you will start getting interviews and scheduling them. These interviews hold for about four months in total, from October, November, December, and January. A few people also interview in February but that’s very rare.

Some interviews are four hours long while some are six hours long. In most cases, you will be interviewed by three people. The first one would be the program director, the second would be the chief resident and the third would be an associated PD or professor. This is not always the case and can vary from person to person. You will then write a thank you letter to every single person which you can send by either post or email.

The Rank Order List and Match

As programs rank applicants, applicants also rank programs based on preference. On the match date, which is usually on Monday in the third week of March right, an email is sent to you stating whether you matched or not. This is based on the rank order list which follows an algorithm. The algorithm matches the program with the applicants based on the rank order list. The next Friday, you get to know which program you match in.

Supplemental Offer and Acceptance Program (SOAP)

The delay between Monday and Friday gives an opportunity for those who did not match to apply for SOAP. This involves calling programs and asking them if they have any unfilled spots which you will try to fill.

USMLE Step 3

USMLE Step 3 is not a requirement to match. You can however still do it before matching. It can increase your chances of matching because since you are already done with Step 3, the program does not have to worry about it.

A lot of people match without taking USMLE Step 3. American Medical Graduates actually cannot take Step 3 before matching because they are in their fourth year of medical school. Only medical graduates are eligible to write it.

Most people take Step 3 in their PGY 1 or PGY 2 and a lot of programs have this requirement where they will not allow you to transition to PGY 3 if you have not passed Step 3.

USMLE Step 3 Questions

Step 3 is a two-day exam. The first day is called Foundations of Independent Practice where you will be tested on your basic sciences and your clinical knowledge just like in Step 1 and Step 2. It is seven hours long and is divided into six blocks, each lasting one hour long. There are about 232 mcqs with 38 to 39 mcqs per block. There is a one-hour interval which is divided into 45 minutes break and a 15-minute orientation. Again if you do the orientation before going for the exam, you can actually convert it into more of your break time.

You don’t necessarily have to write the two exams on consecutive days. You can write them at about a maximum delay of one week. The second day is all about advanced clinical medicine and CCS cases. It is basically a test of your ability on history taking, physical examination and patient care. It is about nine hours long and it’s divided into six blocks of MCQs where one block is about 45 minutes each.

There are 180 MCQs with about 30 MCQs per block. There are also 13 CCS cases after these six blocks. These cases are basically software based cases where you are tested in an artificial simulation on your ability to deliver patient care. CSS cases are some sort of artificial simulations of Step 2 CS.


Aiming for high scores in the USMLE is important but does not guarantee you a residency spot. It is also important to work on your CV, acquire research experiences and get quality letters of recommendation to improve your chances of matching.


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