When you are going through medical school, you may be wondering about important differences between Step 1 and Step 2CK. These are the two licensing exams required to graduate with your medical degree. The osteopathic equivalent of these exams are Level 1 and Level 2CE. These exam are similar in the sense that they are comprehensive. However, they differ in when you take them, the content, question style, and implications for matching.
I have recently taken Step 2CK and Level 2CE, and wanted to discuss important differences between the first set of exams and second. As you prepare for either exam, it can be helpful to know what’s expected of you to learn, and how they are different. If you have already taken Step or Level 1, then this blog post will help you prepare for the different style of exam. Everything in this post also applies to COMLEX Level 1 and Level 2CE for osteopathic students. Continue reading to learn more about the important differences between Step 1 and Step 2CK.
What are Step 1 and Step 2CK?
When you are in medical school, there are three licensing exams you must take to have practicing rights. For allopathic students, these exams are USMLE Step 1, Step 2CK, and Step 3. For osteopathic students, these exams are COMLEX Level 1, Level 2CE, and Level 3. CK stands for clinical knowledge and CE stands for clinical examination. This is differentiated from CS, or clinical skills. CS was an in-person patient simulation exam that has been discontinued since COVID and will not return.
Step 1 and Step 2 are multiple choice, online exams that are taken during medical school, and Step 3 is taken at the end of intern year during residency. Without taking all three exams, you will be unable to be an independently practicing physician. Step 1 is normally taken at the end of year 2, before clinical rotations. Step 2 is taken before graduation, but normally at the end of year 3.
Differences in content between Step 1 and Step 2CK
Step 1 and Step 2CK are completely different exams. They both are about medicine, but have different topics.
Step 1
Step 1 focuses on the basic science knowledge. Topics include:
- Blood & lymphoreticular/immune systems
- Behavioral health and nervous systems/special senses
- Musculoskeletal, skin and subcutaneous tissues
- Cardiovascular system
- Respiratory & renal/urinary systems
- Gastrointestinal system
- Reproductive & endocrine systems
- Multisystem processes & disorders
- Biostatistics & epidemiology/population health
- Social sciences: communication and interpersonal skills
The majority of the exam requires students to interpret graphic and tabular material, identify gross and microscopic pathologic specimens, and normal specimens. Students also must solve problems through the application of basic science principles. Discipline specifications include:
- Pathology
- Physiology
- Pharmacology
- Biochemistry & nutrition
- Microbiology
- Immunology
- Gross anatomy & embryology
- Histology & cell biology
- Behavioral sciences
- Genetics
Step 2CK
Step 2CK assess the ability of the student to apply medical knowledge, skills, and understanding of clinical science. The main focus of Step 2CK ensure that students know the basic clinical sciences, along with basic patient-centered skills that allow for safe practice under supervision. The topics included are:
- Immune system
- Blood and lymphoreticular system
- Behavioral health
- Nervous system & special senses
- Musculoskeletal system/skin & subcutaneous tissue
- Cardiovascular system
- Respiratory system
- Gastrointestinal system
- Renal & urinary system & male reproductive
- Pregnancy, childbirth, and puerperium
- Female reproductive system and breast
- Endocrine system
- Multisystem processes & disorders
- Biostatistics & epidemiology/population health/interpretation of medical literature
- Social sciences: legal/ethical issues & professionalism/systems-based practice & patient safety
The exam tests your ability to answer clinically relevant questions. This includes decision making, interpretation of data, and making very similar decisions like a doctor. The tasks that are involved in these exams include:
- Patient care
- History and physical exam
- Laboratory and diagnostic studies
- Prognosis and outcome
- Health maintenance and disease prevention
- Pharmacotherapy
- Clinical interventions
- Mixed management
- Practice-based learning and improvement
- Professionalism
- Systems-based practice and patient safety
The exam is further broken down into discipline specifications. These reflect the core rotations that you are expected to complete prior to taking the exam. These include:
- Medicine (majority)
- Surgery
- Pediatrics
- Obstetrics & Gynecology
- Psychiatry
Exam differences between Step 1 and Step 2CK
Another aspect of important differences between Step 1 and Step 2CK is how the exams are administered. As stated before, they are both multiple choice exams that are taken electronically. They can be taken at either a Prometric or Pearson VUE testing centers. Available dates and locations can be found on the examination website.
The test lengths are also different. Both exams are one day long. However, Step 1 has 280 questions and is an eight-hour exam. There are seven blocks, each with about 40 questions, sometimes less. Step 2 has 318 questions, and is a nine-hour exam. There are eight blocks, each with about 40 questions, sometimes 38.
COMLEX exams are longer than Step exams. Both COMLEX Level 1 and Level 2CE have 352 questions, and are nine-hour exams divided into eight-blocks.
For the Step exams, you have an hour to complete each question block. However, for Level exams, you have four hours to complete the first four blocks and four hours to complete the second four blocks at your own pace. Once you end a block, however, you may not go back.
The breaks are also different between Step and Level exams. In both Step exams, there are 45 minutes allotted for a break throughout the entire exam. You can use these breaks whenever you need between blocks. Any extra time after a section adds to the break time. COMLEX has designated 10 minute breaks after sections 2 and 6 with a 40-minute lunch after section 4. Any time you use over the breaks will be taken out of your testing time. Breaks are open, as well, meaning you have full access to your materials, and you are allowed to leave the facility. Just make sure you’re back in time!
Differences in question style between Step 1 and Step 2CK
As you are preparing for either exam, it will help you to know the important differences between Step 1 and Step 2CK question style. They are, and distinct, and must be approached differently.
Step 1 exam questions are highly focused on your knowledge of basic sciences. This means questions may test you on identifying the disease based on presentation, genes, gross and microscopic photos, etc. Additionally, the test likes to focus on origins or derivatives. They may present you with a case, but ask you for the mechanism of action of a drug, inheritance pattern of the disease, microscopic characteristics of a disease, etc. An example of a Step 1 question is:
Step 2CK questions, however, focus more on clinical application and management. Therefore, these questions may present you with a patient, and ask you to choose what’s next. The main issue with Step 2CK questions, is that there are often more than one “right” answers. However, they are looking for the best answer. Test questions may also focus on adverse effects of a drug, associated diseases in a syndrome, prevention, emergent management, and interpretation of lab values. A sample question is below:
Differences in preparation materials
Preparing for the two exams will look vastly different. Some argue that Step 2CK preparation is easier than Step 1 preparation. One of the reasons is because Step 1 covers 2 years of information while Step 2 covers just 1 year of information.
The other difference is that throughout clinical rotations, you take end-of-rotation exams, or Shelf exams. The osteopathic equivalent of these exams are COMAT exams. These exams give you repeated exposure to Step 2CK and Level 2CE questions so, you are essentially preparing all year.
For Step 1, your best friend is probably going to be First Aid. First Aid is a comprehensive review book that covers everything you need to know. It’s difficult to use First Aid early in medical school because it requires a general understanding before the book truly makes sense. However, reading through it before taking Step 1 is extremely useful.
UWorld is another great tool for both Step 1 and Step 2CK. It is a test bank that exposes you to multiple board-style questions. The questions are challenging, but adequately prepare you for taking the exam. It’s an expensive resource, but is the gold standard.
For Step 2CK, many medical students prefer OnlineMedEd. This is a video, notes, and flashcard resource that is very comprehensive. They offer a limited, free version where you have access to a few lessons. However, buying their yearly subscription gives you access to their notes, videos, questions, and flashcards for all the lessons. Their yearly plan is $365, but for 25% off, just use the code DARIAN25 when checking out!
For COMLEX preparation, TrueLearn is the best option.
Residency implications of Step 1 and Step 2CK
The most important part of testing is that passing these exams helps you match into residency. However, there are important differences between Step 1 and Step 2CK in how they help your residency pursuits. Many of these differences are new because Step 1 and Level 1 just recently became pass/fail.
What does this mean for medical students?
Well, that’s still to be determined. However, it is widely understood that the weight of Step 2CK has greatly increased because it’s the only scored exam. Therefore, it’s the only standardized academic measurement that residency directors can use to compare you to other applicants. Step 2CK scores range from 1-300 and a passing score is 214. Level 2CE scores range from 9-999 with a mean score of 500-550. A passing score is 400.
Therefore, when taking your exams, it’s imperative that you pass Step 1 and Level 1 on the first try, and score well for Step 2CK and Level 2CK.
Average scores for the various specialties for Step 2CK and Level 2CE are:
Key takeaways
These are just a few of the important differences between Step 1 and Step 2CK. If you are studying for Step 1, it’s important to know enough to just pass. If you are studying for Step 2CK, it’s important to find the nuances for a higher score. I based the material in this blog post on my own experiences. If you have any additional tips or more questions, please leave them in the comments. I am also available by email to answer more question. Good luck on all of your exams, and you got it!