USMLE Step &amp; NBME Shelf Exam Topics, Criteria &amp; Blueprints

Practice Step 2 CK Vignettes

USMLE National BoardAmbulatory (50%–55%)

USMLE Step 2 Clinical Knowledge (Step 2 CK)

Overview USMLE Outline

Assessment of clinical science knowledge, diagnostic acumen, and supervised patient management essential for clinical practice, with heavy emphasis on health promotion, disease prevention, and acute/chronic clinical interventions.

Testing Format: 16 blocks • Up to 318 questions (30 min/block • Scored 3-digit scale, 218 passing floor)

Sites of Care: Ambulatory (50%–55%), Inpatient (35%–40%), Emergency Department (10%–15%)

Patient Demographics: Pediatric (17%–27%), Adult (55%–65%), Geriatric (15%–20%)

Complete Official Blueprint Specifications28 Metrics

System-Based Content Specifications

Renal & Urinary System & Reproductive Systems7%–13%

Cardiovascular System6%–12%

Musculoskeletal System / Skin & Subcutaneous Tissue6%–12%

Behavioral Health5%–10%

Blood & Lymphoreticular / Immune Systems5%–10%

Gastrointestinal System5%–10%

Nervous System & Special Senses5%–10%

Respiratory System5%–10%

Multisystem Processes & Disorders4%–8%

Endocrine System3%–7%

Pregnancy, Childbirth & the Puerperium3%–7%

Biostatistics & Epidemiology / Population Health3%–5%

Human Development2%–4%

Core Clinical Tasks & Competencies

Prioritizing next best diagnostic test vs immediate therapeutic intervention
Managing acute medical, pediatric, and surgical emergencies in the ED and ICU
Implementing USPSTF-recommended screening guidelines and vaccination schedules
Quality improvement, patient safety protocols, root cause analysis, and clinical ethics

National PA Certifying Board (NCCPA)Emergency Department

Physician Assistant National Certifying Examination (PANCE)

Overview NCCPA Outline

Comprehensive evaluation of general medical and surgical knowledge, clinical decision-making, diagnostic reasoning, pharmacotherapy, and clinical interventions required for entry-level physician assistant clinical practice.

Testing Format: 5 blocks • 300 questions (60 min/block • 5 hours total • Passing Score: 350 on 200–800 scale)

Sites of Care: Emergency Department, Inpatient Ward, Ambulatory Primary Care Clinic, Operating Room

Patient Demographics: Full Lifespan (Infant, Pediatric, Adolescent, Adult, Geriatric)

Complete Official Blueprint Specifications25 Metrics

Table 1: NCCPA Organ System Content Weightings

Cardiovascular System13%

Pulmonary System10%

Gastrointestinal System / Nutritional9%

Musculoskeletal System8%

Eyes, Ears, Nose, and Throat (EENT)7%

Reproductive System (Male & Female)7%

Endocrine System6%

Neurologic System6%

Infectious Diseases6%

Psychiatry / Behavioral Science6%

Dermatologic System5%

Genitourinary System (Male & Female)5%

Renal System / Nephrology5%

Hematologic System4%

Core Clinical Tasks & Competencies

Performing focused and comprehensive clinical history and physical examinations across all organ systems
Formulating evidence-based differential and most likely diagnoses under time constraints
Interpreting 12-lead electrocardiograms, clinical laboratory values, and diagnostic imaging studies
Prescribing and monitoring guideline-directed first-line pharmacotherapies and recognizing toxicities
Executing clinical and minor surgical bedside interventions safely and managing complications
Recommending age-appropriate health maintenance, immunization schedules, and risk reduction strategies

Practice PANCE Vignettes

Practice PACKRAT Vignettes

PAEA Clinical MilestoneAmbulatory Care (50%)

PA Clinical Knowledge Rating and Assessment Tool (PACKRAT)

Overview NCCPA Outline

Comprehensive formative clinical knowledge benchmarking developed by the Physician Assistant Education Association (PAEA) to assess didactic mastery and readiness for clinical rotations and the PANCE.

Testing Format: 225 multiple-choice questions • 4 hours testing window (Formative Evaluation)

Sites of Care: Ambulatory Care (50%), Inpatient Hospital (25%), Emergency Department (20%), Operating Room (5%)

Patient Demographics: Full Lifespan (Pediatric to Geriatric)

Complete Official Blueprint Specifications14 Metrics

Core Clinical Specialty Distribution

Internal Medicine / Adult Medicine35%–40%

Emergency Medicine15%–20%

Family Medicine / Ambulatory Care15%–20%

General Surgery & Subspecialties10%–15%

Pediatrics10%–15%

Women’s Health / Obstetrics & Gynecology8%–12%

Psychiatry & Behavioral Health6%–10%

Core Clinical Tasks & Competencies

Benchmarking didactic knowledge retention prior to entering clinical rotation clerkships
Identifying knowledge deficits across high-yield outpatient and inpatient clinical scenarios
Calibrating question-pacing stamina for national certifying board standards

Practice PA EOR Suite Vignettes

PAEA Clinical MilestoneRotations: Outpatient Clinics

PAEA End of Rotation (EOR) Clinical Specialty Examinations

Overview NCCPA Outline

Standardized, rigorous objective clinical assessments administered at the completion of each core clinical rotation during the PA clinical year to evaluate clerkship-specific competence.

Testing Format: 7 modular rotation exams • 120 questions each (100 scored, 20 pretest • 2 hours/exam)

Sites of Care: Rotations: Outpatient Clinics, Inpatient Wards, Emergency Department, Surgical Suites

Patient Demographics: Rotation-Specific (Pediatrics, Adults, Geriatrics, Obstetric/Gynecologic)

Complete Official Blueprint Specifications14 Metrics

The 7 Core Clinical Rotation Modular Blueprints

Family Medicine Rotation Exam (120 Qs)Primary Care, Chronic Disease, Preventive Care

Internal Medicine Rotation Exam (120 Qs)High-Acuity Inpatient Medicine & Subspecialties

Emergency Medicine Rotation Exam (120 Qs)Acute Resuscitation, Trauma, Toxicology

General Surgery Rotation Exam (120 Qs)Pre-op, Intra-op & Post-op Surgical Management

Pediatrics Rotation Exam (120 Qs)Developmental Milestones, Neonatal & Childhood Illness

Women’s Health Rotation Exam (120 Qs)Prenatal Care, Labor/Delivery, GYN Pathology

Psychiatry & Behavioral Health Exam (120 Qs)DSM-5-TR Diagnostic Criteria & Psychopharmacology

Core Clinical Tasks & Competencies

Demonstrating clerkship-specific clinical mastery across all 7 core physician assistant rotations
Correlating patient presentation history and physical findings with definitive diagnostic criteria
Implementing rotation-specific evidence-based clinical algorithms and procedural care

Third-Year Clerkship100% Ambulatory / Outpatient Clinical Setting

Ambulatory Care Subject Examination

Practice Ambulatory Care Vignettes

Outpatient medicine across general adult and elderly populations, focusing on longitudinal disease management, symptom differentiation, chronic condition titration, and evidence-based preventive screenings.

Testing Format: 110 items • 2 hours 45 minutes (EPC scale 0–100)

Sites of Care: 100% Ambulatory / Outpatient Clinical Setting

Patient Demographics: Adult (60%–70%), Geriatric (20%–25%), Pediatric (10%–15%)

Complete Official Blueprint Specifications17 Metrics

Organ System Blueprint Specifications

Cardiovascular System10%–15%

Respiratory System10%–15%

Musculoskeletal System10%–15%

Endocrine & Metabolic Disorders8%–12%

General Principles, Normal Age-Related Findings & Well Patient5%–10%

Behavioral Health5%–10%

Gastrointestinal System5%–10%

Renal & Urinary System5%–10%

Nervous System & Special Senses5%–10%

Blood & Lymphoreticular System1%–5%

Immune System1%–5%

Skin & Subcutaneous Tissue1%–5%

Social Sciences (Communication, Medical Ethics)1%–5%

Core Clinical Tasks & Competencies

Evaluation of undifferentiated outpatient symptoms (cough, chest pain, fatigue, joint swelling)
Management of chronic hypertension, type 2 diabetes mellitus, hyperlipidemia & osteoarthritis
Implementing USPSTF age- and sex-stratified screening guidelines & adult immunization schedules
Cost-conscious diagnostic test ordering and avoidance of low-value clinical interventions

Third-Year ClerkshipInpatient Floors (40%–45%)

Clinical Neurology Subject Examination

Practice Neurology Vignettes

Neurologic localization, neuromuscular pathology, acute stroke protocols, epilepsy, cognitive impairment, and outpatient neuro-pharmacology across inpatient and ambulatory settings.

Testing Format: 110 items • 2 hours 45 minutes (EPC scale 0–100)

Sites of Care: Inpatient Floors (40%–45%), Ambulatory Clinic (35%–40%), Emergency Department (15%–20%)

Patient Demographics: Adult (65%–75%), Geriatric (20%–25%), Pediatric (5%–10%)

Complete Official Blueprint Specifications11 Metrics

Organ System Blueprint Specifications

Nervous System & Special Senses60%–65%

Musculoskeletal System10%–15%

Multisystem Processes & Disorders5%–10%

Behavioral Health & Neuropsychiatry3%–7%

Cardiovascular System (Vascular / Stroke)3%–7%

General Principles, Age-Related Findings & Well Patient1%–5%

Social Sciences1%–5%

Core Clinical Tasks & Competencies

Neuroanatomic lesion localization (cortex, subcortical, brainstem, spinal cord, nerve, NMJ)
Management of acute ischemic stroke, tPA/thrombectomy inclusion/exclusion & hemorrhage triage
Classification and pharmacological selection for focal vs generalized seizure disorders
Evaluation of movement disorders (Parkinson, essential tremor), demyelinating disease & myasthenia

Third-Year ClerkshipAmbulatory Primary Care (85%–90%)

Family Medicine Modular Subject Examination

Practice Family Medicine Vignettes

Comprehensive primary care covering acute undifferentiated illnesses, chronic disease stabilization, maternal-child health, and preventive surveillance across all age brackets.

Testing Format: 100–110 items (Core + Modular Sections) • 2 hours 45 minutes (EPC scale 0–100)

Sites of Care: Ambulatory Primary Care (85%–90%), Urgent / Inpatient (10%–15%)

Patient Demographics: Pediatric (15%–20%), Adult (50%–55%), Geriatric (25%–30%)

Complete Official Blueprint Specifications11 Metrics

Core Clinical Domain Specifications

Chronic Disease Management (HTN, Diabetes, COPD, Lipids)25%–30%

Health Maintenance, USPSTF Screening & Immunizations20%–25%

Acute Undifferentiated Illness & Triage15%–20%

Musculoskeletal & Sports-Related Injuries10%–15%

Behavioral Health across Lifespan10%–15%

Maternal Health & Care of the Well Child5%–10%

Healthcare Systems, Communication & Ethics3%–7%

Core Clinical Tasks & Competencies

Diagnostic workup of initial presenting symptoms (fatigue, rash, joint pain, abdominal cramps)
Management of metabolic syndrome, diabetes regimens, glycemic targets & statin indications
Well-child examinations, milestone surveillance, and developmental red flags
Shared decision-making for prostate, breast, colorectal, and cervical cancer screenings

Third-Year ClerkshipInpatient Medical Floors (40%–45%)

Medicine Subject Examination (Internal Medicine)

Practice Internal Medicine Vignettes

Adult inpatient and outpatient internal medicine subspecialties, complex multi-organ disease processes, diagnostic lab interpretation, and inpatient pharmacology.

Testing Format: 100 items • 2 hours 30 minutes (or 110 items • 2h 45m) (EPC scale 0–100)

Sites of Care: Inpatient Medical Floors (40%–45%), Ambulatory Clinic (35%–40%), Emergency Department (20%–25%)

Patient Demographics: Adult (70%–80%), Geriatric (20%–30%)

Complete Official Blueprint Specifications18 Metrics

Organ System Blueprint Specifications

Cardiovascular System12%–16%

Respiratory System10%–15%

Gastrointestinal System & Hepatology10%–14%

Renal & Urinary System8%–12%

Endocrine System & Metabolism8%–12%

Blood & Lymphoreticular System6%–10%

Nervous System & Special Senses6%–10%

Musculoskeletal & Rheumatology / Connective Tissue6%–10%

Multisystem Processes (Shock, Sepsis, Toxins)6%–10%

Infectious Diseases6%–10%

Behavioral Health3%–7%

Immune System2%–5%

Skin & Subcutaneous Tissue2%–5%

Social Sciences2%–5%

Core Clinical Tasks & Competencies

Differential diagnosis for complex multimorbid inpatient admissions
Management of acute decompensated heart failure, ACS, COPD exacerbation & PE
Acid-base interpretation, anion gap calculation, and renal failure etiology differentiation
Antimicrobial stewardship, empiric hospital-acquired coverage & infectious disease de-escalation

Third-Year ClerkshipAmbulatory Clinic (70%–75%)

Obstetrics and Gynecology Subject Examination

Practice OB/GYN Vignettes

Maternal-fetal medicine, labor and delivery complications, reproductive endocrinology, gynecologic oncology, contraception, and primary women’s healthcare.

Testing Format: 110 items • 2 hours 45 minutes (EPC scale 0–100)

Sites of Care: Ambulatory Clinic (70%–75%), Labor & Delivery / Inpatient (20%–25%), Emergency (5%–10%)

Patient Demographics: Reproductive Age Female (80%–85%), Postmenopausal Female (15%–20%)

Complete Official Blueprint Specifications9 Metrics

Primary Clinical Domain Specifications

Obstetrics (Antepartum, Intrapartum, Postpartum, Fetal Monitoring)45%–50%

Gynecology (Benign Gyn, Pelvic Pain, Gyn Oncology, Infertility)45%–50%

Endocrine System & Reproductive Endocrinology5%–10%

Multisystem Processes & Disorders3%–7%

Social Sciences, Ethics & Patient Communication2%–5%

Core Clinical Tasks & Competencies

Interpretation of electronic fetal monitoring strips (Category I, II, III) & labor arrest
Management of hypertensive disorders of pregnancy (preeclampsia, eclampsia, HELLP syndrome)
Differential diagnosis of abnormal uterine bleeding across premenopausal and postmenopausal women
Workup of adnexal masses, pelvic inflammatory disease, ectopic pregnancy, and ovarian torsion

Third-Year ClerkshipAmbulatory / Outpatient Clinic (65%–70%)

Pediatrics Subject Examination

Practice Pediatrics Vignettes

Normal growth and development, neonatal transition, pediatric infectious illnesses, congenital disorders, pediatric emergency stabilization, and adolescent health.

Testing Format: 110 items • 2 hours 45 minutes (EPC scale 0–100)

Sites of Care: Ambulatory / Outpatient Clinic (65%–70%), Emergency Department (20%–25%), Inpatient / NICU (12%–16%)

Patient Demographics: Neonate (<1 mo) 10%–15%, Infant/Toddler (1 mo–2 yr) 25%–30%, Child (3–11 yr) 30%–35%, Adolescent (12–18 yr) 25%–30%

Complete Official Blueprint Specifications17 Metrics

Organ System Blueprint Specifications

General Principles, Normal Growth & Development, Well Child15%–20%

Respiratory System (Asthma, Bronchiolitis, Croup, Pneumonia)12%–16%

Gastrointestinal System & Pediatric Nutrition10%–14%

Cardiovascular System (Congenital Heart Defects, Murmurs)8%–12%

Infectious Diseases & Childhood Immunizations8%–12%

Blood, Lymphoreticular & Pediatric Oncology6%–10%

Nervous System & Neurodevelopmental Disorders6%–10%

Renal, Urinary System & Fluid/Electrolytes5%–9%

Multisystem Processes (Sepsis, Inborn Errors of Metabolism)5%–9%

Musculoskeletal System & Pediatric Orthopedics4%–8%

Behavioral Health & Adolescent Medicine4%–8%

Skin & Subcutaneous Tissue (Pediatric Exanthems)3%–7%

Endocrine Disorders (Growth Failure, DKA)3%–6%

Core Clinical Tasks & Competencies

Developmental milestones surveillance (gross motor, fine motor, language, social)
Management of acute pediatric respiratory distress (croup, bronchiolitis, asthma, epiglottitis)
Workup of pediatric fever without a source, neonatal sepsis rules, and meningitis protocols
Fluid resuscitation, maintenance fluid calculations (Holliday-Segar), and dehydration staging

Third-Year ClerkshipInpatient Psychiatric Unit (40%–45%)

Psychiatry Subject Examination

Practice Psychiatry Vignettes

Psychiatric diagnostic criteria (DSM-5-TR), psychopharmacology mechanism and side-effect profiles, addiction medicine, emergency crisis interventions, and psychotherapy modalities.

Testing Format: 110 items • 2 hours 45 minutes (EPC scale 0–100)

Sites of Care: Inpatient Psychiatric Unit (40%–45%), Ambulatory Clinic (40%–45%), Emergency / Consultation-Liaison (15%–20%)

Patient Demographics: Adult (65%–75%), Geriatric (Dementia, Delirium) 15%–20%, Child & Adolescent (10%–15%)

Complete Official Blueprint Specifications9 Metrics

Clinical System & Domain Specifications

Behavioral Health & Psychiatric Disorders65%–70%

Nervous System & Special Senses (Neuropsychiatry, Cognitive)10%–15%

General Principles, Psychosocial Factors & Well Patient5%–10%

Multisystem Processes (Toxicology, Withdrawal, Serotonin Syndrome)5%–10%

Social Sciences (Commitment, Ethics, Capacity, Boundary Issues)2%–5%

Core Clinical Tasks & Competencies

Diagnostic differentiation of major mood disorders (Bipolar I, II, MDD with psychotic features)
Management of acute psychiatric emergencies: suicidality, neuroleptic malignant syndrome & lithium toxicity
Pharmacologic side-effect management (metabolic syndrome, EPS, tardive dyskinesia, QTc prolongation)
Differential diagnosis of cognitive impairment: delirium vs dementia vs depression pseudo-dementia

Third-Year ClerkshipInpatient Floors & ICU (50%–55%)

Surgery Subject Examination

Practice Surgery Vignettes

General surgery, surgical oncology, trauma resuscitation, preoperative evaluation, postoperative complication management, surgical critical care, and common surgical subspecialties.

Testing Format: 110 items • 2 hours 45 minutes (EPC scale 0–100)

Sites of Care: Inpatient Floors & ICU (50%–55%), OR & PACU (20%–25%), Emergency Department / Trauma (15%–20%), Outpatient Clinic (10%–15%)

Patient Demographics: Adult (70%–75%), Geriatric (20%–25%), Pediatric (5%–10%)

Complete Official Blueprint Specifications16 Metrics

Organ System Blueprint Specifications

Gastrointestinal System & Abdominal Wall20%–25%

Cardiovascular System (Vascular, Aortic, Cardiac)10%–15%

Respiratory System & Thoracic Surgery8%–12%

Multisystem Processes (Trauma, Hemorrhagic Shock, Burns, Sepsis)8%–12%

Blood & Lymphoreticular (Hemostasis, Transfusion, Coagulopathy)5%–10%

Nervous System & Neurosurgery (TBI, Intracranial Bleeds)5%–10%

Musculoskeletal System & Orthopedics3%–7%

Renal & Urinary System (Urology)3%–7%

Female Reproductive System & Breast Oncology3%–7%

Endocrine Surgery (Thyroid, Parathyroid, Adrenals)3%–7%

Skin & Soft Tissue (Melanoma, Sarcoma, Necrotizing Infections)2%–5%

Immune System & Transplant Surgery1%–5%

Social Sciences, Informed Consent & Surgical Ethics1%–5%

Core Clinical Tasks & Competencies

Acute abdomen triage: appendicitis, cholecystitis, diverticulitis, bowel obstruction & perforation
Advanced trauma life support (ATLS) primary and secondary survey execution and hemorrhagic shock control
Management of postoperative complications: fever workup (5 Ws), wound dehiscence, DVT/PE, atelectasis
Preoperative risk stratification (cardiac, pulmonary, hepatic) and nutritional optimization

Fourth-Year Sub-Internship100% Emergency Department & Trauma Resuscitation Bay

Emergency Medicine Advanced Clinical Examination

Practice Emergency Medicine Vignettes

Resuscitation protocols, rapid triage, undifferentiated emergency presentations, bedside ultrasound (POCUS), toxidromes, traumatic injuries, and immediate stabilization.

Testing Format: 100 items • 2 hours 15 minutes (EPC scale 0–100)

Sites of Care: 100% Emergency Department & Trauma Resuscitation Bay

Patient Demographics: Adult (65%–70%), Geriatric (20%–25%), Pediatric (10%–15%)

Complete Official Blueprint Specifications13 Metrics

Clinical System Blueprint Specifications

Cardiovascular Emergencies (ACS, Dysrhythmias, Aortic Dissection)15%–20%

Respiratory Emergencies (PE, Respiratory Failure, Asthma/COPD, PTX)15%–20%

Multisystem Processes (Trauma Resuscitation, Shock, Toxicology)15%–20%

Gastrointestinal Emergencies (Acute Abdomen, GI Bleed, Obstruction)10%–15%

Nervous System Emergencies (Stroke/TIA, Status Epilepticus, Altered Mental Status)8%–12%

Musculoskeletal Emergencies (Fractures, Dislocations, Compartment Syndrome)6%–10%

Renal, Genitourinary & Pelvic Emergencies5%–8%

Infectious Diseases & Sepsis Resuscitation5%–8%

Behavioral & Psychiatric Emergencies (Agitation, Overdose)3%–6%

Blood & Immune Emergencies (Anaphylaxis, Bleeding Diatheses)2%–5%

Core Clinical Tasks & Competencies

Rapid airway stabilization, mechanical ventilation induction, and central access placement
Management of acute cardiogenic, septic, hypovolemic, and anaphylactic shock states
Identification of life-threatening toxidromes (anticholinergic, sympathomimetic, cholinergic, opioid)
Triage decision-making: critical care admission vs observation vs safe discharge with follow-up

Fourth-Year Sub-InternshipInpatient Acute Medical Floors (60%–65%)

Advanced Internal Medicine Clinical Examination (Sub-Internship)

Practice Advanced Medicine Vignettes

High-acuity inpatient internal medicine ward care, ICU stepdown management, complex diagnostic reasoning in multimorbid patients, and perioperative medical consultations.

Testing Format: 100 items • 2 hours 15 minutes (EPC scale 0–100)

Sites of Care: Inpatient Acute Medical Floors (60%–65%), Intensive Care Unit / Stepdown (25%–30%), Emergency Admission / Triage (10%–15%)

Patient Demographics: Adult (60%–70%), Geriatric (30%–40%)

Complete Official Blueprint Specifications13 Metrics

Clinical System Blueprint Specifications

Cardiovascular Disorders (Refractory Heart Failure, Arrhythmias, Shock)15%–20%

Pulmonary & Critical Care Medicine (ARDS, Severe Sepsis, Ventilators)15%–20%

Renal, Fluid/Electrolyte & Complex Acid-Base Disorders12%–16%

Gastrointestinal, Hepatic & Biliary (Cirrhosis Decompensation, Pancreatitis)10%–14%

Infectious Diseases (Hospital-Acquired, Sepsis, Immunocompromised Host)10%–14%

Hematology & Oncology (Febrile Neutropenia, Hypercalcemia, Coagulopathies)8%–12%

Endocrine Emergencies (DKA, HHS, Adrenal Crisis, Myxedema)6%–10%

Nervous System & Inpatient Delirium / Encephalopathy5%–8%

Multisystem Organ Failure5%–8%

Core Clinical Tasks & Competencies

Managing multi-organ failure, pressor selection, and hemodynamic stabilization on inpatient wards
Evaluation and diagnostic workup of acute kidney injury with complex mixed acid-base disorders
Diagnostic evaluation and antimicrobial escalation for hospital-acquired and opportunistic infections
Comprehensive discharge planning, medication reconciliation, and care transitions for multimorbid patients

Comprehensive MilestoneAmbulatory (50%–55%)

Comprehensive Clinical Science Examination (CCSE)

Broad clinical readiness milestone mirroring the USMLE Step 2 CK blueprint, assessing integrated clinical reasoning, disease prevention, diagnosis, and management across all medical disciplines.

Testing Format: 4 blocks • 200 questions (Scored on USMLE 3-digit scale)

Sites of Care: Ambulatory (50%–55%), Inpatient (35%–40%), Emergency Department (10%–15%)

Patient Demographics: Comprehensive Lifespan: Pediatric 20%, Adult 60%, Geriatric 20%

Complete Official Blueprint Specifications20 Metrics

Clinical Science Disciplines (Step 2 CK Framework)

Medicine (Internal Medicine)50%–60%

Pediatrics15%–25%

Obstetrics & Gynecology10%–20%

Surgery10%–15%

Psychiatry10%–15%

Core Clinical Tasks & Competencies

Comprehensive multi-specialty clinical reasoning spanning adult medicine, pediatrics, surgery, OB/GYN, and psychiatry
Integration of laboratory findings, imaging, and patient presentation into accurate primary and secondary diagnoses
Prioritizing pharmacotherapy interventions, surgical consults, and procedural choices based on clinical urgency
Execution of preventive care, adult and pediatric immunization schedules, and screening algorithms

Practice CCSE Vignettes

Comprehensive MilestoneHealth System Enterprise-wide (Inpatient

Health Systems Science Subject Examination

Practice Health Systems Vignettes

Patient safety culture, root cause analysis, healthcare economics and financing, high-value care principles, clinical informatics, population health, and interprofessional teamwork (developed in partnership with the AMA).

Testing Format: 100 items • 2 hours 15 minutes (EPC scale 0–100, developed with AMA)

Sites of Care: Health System Enterprise-wide (Inpatient, Ambulatory, Public Health, Community)

Patient Demographics: All Clinical Populations & Vulnerable Groups

Complete Official Blueprint Specifications12 Metrics

Core & Cross-Cutting Domains (AMA Curriculum)

High-Value Care & Patient Safety (Error Disclosure, RCA)23%–27%

Evidence-Based Practice & Information Mastery18%–22%

Health Care Structures & Processes (Care Models, Payment)13%–17%

Quality Improvement (PDSA Cycles, Run Charts, Six Sigma)13%–17%

Health Care Economics & Policy (Insurance, Financing)8%–12%

Clinical Informatics & EHR (Decision Support, Safety)8%–12%

Population & Public Health (SDOH, Health Inequities)5%–10%

Leadership & Teamwork (Interprofessional Practice)5%–10%

Core Clinical Tasks & Competencies

Performing root cause analysis (RCA) and Swiss Cheese Model event deconstructions following adverse safety events
Designing Plan-Do-Study-Act (PDSA) quality improvement cycles and reading statistical process control run charts
Evaluating diagnostic test characteristics: sensitivity, specificity, positive/negative predictive values & likelihood ratios
Navigating health insurance structures (Medicare, Medicaid, commercial), value-based purchasing, and ACO frameworks