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Special Purpose Examination (SPEX)


The Special Purpose Examination (SPEX) was initially conceived in 1986 by the Federation of State Medical Boards (FSMB) for state medical boards to use as an assessment tool when endorsing or granting licensing reciprocity to a physician licensed in another US state or Canadian province. Its purpose was later expanded to include cases in which state boards needed to assess a physician’s competence before reinstating or reactivating a lapsed or suspended license.

The first SPEX was given in 1988. It was a written, 450-question multiple choice test given 4 times a year. Only 22 physicians sat for the first SPEX, but as the number of member boards using the tool grew, hundreds of candidates took the exam. The FSMB and National Board of Medical Examiners (NBME) recognized the need to make the SPEX more accessible, efficient, and easier to schedule and collaborated in an effort to convert the SPEX to a 420-question, computer-based exam, which replaced the paper-and-pencil test in the fall of 1995.

Initial content was drawn from a pool of questions used in the various state licensing examinations for new physicians. The test pool since has evolved into a purpose-built, standardized test item library used nationwide. Questions are designed to insure that the level of general medical knowledge in currently licensed physicians is at least equal to that of someone seeking licensure for the first time.

In 1998, the SPEX became included in the Post-Licensure Assessment System (PLAS) jointly administered by the FSMB and NBME under the auspices of a specially created SPEX Program Committee.[1]

Function of the Test

SPEX Study Guide

SPEX is a tool for assessing a physician’s level of general medical knowledge that is given only to physicians who hold, or have previously held, an unrestricted medical license in order to determine their overall competence in general medical practice. SPEX is not a licensing examination, nor does passing the SPEX automatically grant an individual the right to practice medicine. Individual state medical boards may require a physician to take the SPEX if his or her license has been inactivated or suspended, whether due to the individual’s choice or as a result of disciplinary action. Some states may also require the SPEX when a physician who was previously licensed for some time in another state applies for licensure by endorsement in the new jurisdiction. [2]

The majority of physicians who sit for the SPEX do so in order to transfer their license from one state to another. Of the more than 150 physicians who took the exam in 2013, 42% were self-nominated and 48% were state board-sponsored. [3]

Scoring standards were initially set by the FLEX board and have been verified several times by independent physician groups. Physicians who hold an active, non-restricted license taking the exam for the first time and who are self-nominated or otherwise taking the test in order to obtain licensure in another state typically score highest, with a pass rate of 82%. The pass rate among those seeking reinstatement of lapsed or revoked licenses who are taking the test for the first time is 70%. Few candidates who fail on their first attempt pass on subsequent attempts; the pass rate among repeaters is only 30%.[4]

Test Administration

SPEX Flashcards

Candidates for the SPEX may be “board-sponsored” or “self-nominated”. The application process for board-sponsored candidates varies by state, based on the requirements of individual medical boards. Required application materials must be submitted by mail to the FSMB along with a $1300 examination fee. Once an application is approved, a Scheduling Permit is sent to the applicant with instructions for scheduling their examination. There is a 90-day eligibility window for taking the test which can be extended only with FSMB approval. A one-time, 90-day extension incurs a processing fee of $65. [5]

Examinations are administered by Prometric at over 300 testing centers across the United States and in Canada. An online search tool allows candidates to select from multiple test centers and dates within driving distance from their location. [6]

Exams can be cancelled or rescheduled during the 90-day eligibility period without incurring a fee by giving Prometric two business days’ notice. Candidates who cancel without rescheduling within their eligibility period may be eligible for a $650 refund from the FSMB. However, anyone who fails to take the exam within the eligibility period and does not provide Prometric with adequate notice will forfeit the entire $1300 examination fee. To schedule an exam once the eligibility deadline has passed, candidates must repeat the application process and pay another $1300 fee. [7]

Self-nominees who fail the SPEX may reapply, submit a new $1300 application fee, and retake the exam for a second time with no waiting period. A third attempt may be made after waiting 90 days from the date of the last exam taken; however, no more than 3 attempts may be made during any 12-month period. Requirements and waiting periods for state board-sponsored candidates are set by the individual state medical boards.[8]

Candidates with special needs as defined under the Americans with Disabilities Act (ADA) can request special testing accommodations in writing when they submit their application. Those with physical disabilities must demonstrate a current, medically diagnosed disability that interferes with their ability to use standard accommodations. Additional detailed documentation must be supplied by those requesting accommodations for learning disabilities. If any physical aids such as cushions or visual aids are needed, these must be requested by writing directly to the FSMB prior to or when submitting the SPEX application.[9]

Test Format

Test Environment

The SPEX takes place at Prometrix Testing Centers. There, each candidate is required to arrive at least half an hour before the exam is scheduled to begin. Two forms of ID are required for admission, one of which must be a government issued photo ID. No personal items are allowed in the examination room. These include electronic devices, outerwear, food and beverages, study material, and bags. The entire testing period, including break and tutorial will consist of about eight hours.[10]

Test Structure

The SPEX, or the Special Purpose Examination covers general medical knowledge that is considered essential for all physicians to know. Questions on the exam will cover Disease Categories, Physician Tasks, Applying Scientific Concepts formulating a diagnosis, and managing patient care. There are seven blocks of questions that contain 48 multiple choice questions each block. Each of the seven blocks allow 64 minutes.[11]

Test Content

  • Sample SPEX Questions
  1. A 57-year-old man comes to see you because of intermittent chest pain. It sometimes occurs with effort, and sometimes at rest, and usually lasts 5 to 10 minutes. It is midsternal with some radiation to the throat. He has a history of high blood pressure. He discontinued smoking at about age 50. His only medication is amlodipine 10 mg daily. He has a family history of hypertension and diabetes type 2. He denies other significant medical problems. On examination his blood pressure is 135/85, pulse 76 and regular, height 70 inches and weight 210 lb. His chest is clear and no cardiac murmurs or rubs are heard. The balance of the examination is negative. His electrocardiogram (ECG) is normal. What is the next logical procedure most likely to provide a diagnosis?
    A. Lipid profile
    B. Hemoglobin A1c
    C. Technetium Tc-99m sestamibi stress test
    D. Coronary angiography
    E. Esophagogastroduodenoscopy (EGD)
  2. A 25-year-old single man is seen for a routine preemployment physical. His medical history reveals an appendectomy at age 16 but no serious medical illness. He had a febrile illness with swollen glands, fatigue, and fever to 101° several months ago, but it resolved by itself and he did not see a doctor. Further questioning reveals that he is bisexual and has had sexual encounters with men and women but has a steady girlfriend at this time. He is vague about condom use. He denies sexually transmitted disease or intravenous drug use but occasionally snorts a little cocaine. Physical examination is essentially negative except for the appendectomy scar. No oropharyngeal abnormalities are noted and there is no evidence of lymphadenopathy or hepatosplenomegaly. A chest x-ray is negative. CBC, liver function tests, VDRL, and hepatitis panel are all negative. An HIV screening test is positive and confirmed by Western blot. A purified protein derivative (PPD) test is negative. What is an appropriate next course of action with this patient?
    A. Observation only with repeat examination and blood tests in 6 months
    B. Observation only with HIV testing of his girlfriend
    C. Begin highly active antiretroviral therapy (HAART)
    D. Obtain a CD4 T-lymphocyte count
    E. Obtain a CD4 T-lymphocyte count and a plasma HIV RNA determination
  3. A 30-year-old man presents with fatigue, nausea, and dark urine for about a week and is evaluated in your clinic. He denies sex with men or sexually transmitted disease but admits to some alcohol abuse and heroin use with needle sharing. He had mononucleosis as a teenager but has no history of hepatobiliary disease or blood transfusion. Laboratory values include markedly elevated aminotransferases with mild LDH, direct/total bilirubin, and alkaline phosphatase elevations. HIV and VDRL tests are negative. Antibody tests for hepatitis A, B, and C are negative. IgG levels are normal and ANA and anti-liver cytosol type 1 antibody tests are also negative and a gamma-glutamyl transferase (GGT) level is also normal. What is the most likely diagnosis?
    A. Acute viral hepatitis A
    B. Acute viral hepatitis B
    C. Acute viral hepatitis C
    D. Cholestatic jaundice
    E. Autoimmune hepatitis
  4. An 18-year-old woman consults you for easy bruising and menorrhagia. Her gynecologist reports a normal pelvic exam. Further history reveals bruising after minor trauma from childhood, occasional spontaneous epistaxis, and heavy periods since menarche at age 13. She has had no surgery but she did experience persistent bleeding after a dental extraction and the dentist recommended a workup for a bleeding disorder. She has had no deep intramuscular or joint bleeding. She is not taking aspirin or other drugs that disturb platelet function. She was adopted so family history is absent. Her physical exam is normal except for some bruises on the extremities. A mild iron deficiency anemia is present. Which of the following laboratory tests is most likely to confirm the clinical diagnosis?
    A. Prothrombin time (PT)
    B. Activated partial thromboplastin time (aPTT)
    C. Ristocetin-induced platelet aggregation (RIPA)
    D. Platelet count
    E. Factor VIII assay

More free SPEX practice test questions.


The SPEX is a multiple-choice exam in which there is only one right answer per question. Raw scores are calculated based on the number of correct answers, and then converted to a two-digit scaled score. Since only correct answers are counted, there is no penalty for guessing when the answer to a question is unknown.[12]

The FSMB releases SPEX scores within 2-4 weeks of a candidate’s exam date. Score reports are sent via postal mail to the candidate and, in the case of board-sponsored candidates, to the appropriate medical board. FSMB recommends a threshold of 75 as a passing score, but each state’s medical board establishes its own passing requirements. Note that this means a scaled score of 75, not a score of 75%.[13]


  1. ^ Federation Bulletin Vol 86 Number 3: The Post Licensure Assessment System October 1, 2014
  2. ^ SPEX Information Bulletin September 30, 2014
  3. ^ NBME 2103 Annual Report October 1, 2014
  4. ^ Federation Bulletin Vol 86 Number 3: The Post Licensure Assessment System October 1, 2014
  5. ^ Special Purpose Examination (SPEX®): Part 3 – Requirements September 30, 2014
  6. ^ For Test Takers: Locate a Test Center September 30, 2014
  7. ^ Special Purpose Examination (SPEX®): Part 3 – Requirements September 30, 2014
  8. ^ SPEX FAQ October 1, 2014
  9. ^ Request for Test Accommodations for Examinees with Disabilities Taking the Special Purpose Examination (SPEX®) October 1, 2014
  10. ^ SPEX Information Bulletin 4 January 2014
  11. ^ FAQ 5 January 2014
  12. ^ Special Purpose Examination (SPEX®): Information Bulletin October 1, 2014
  13. ^ Special Purpose Examination (SPEX®): Score Reporting October 1, 2014