The USMLE Step 1 is among the most pivotal milestones of medical school. It serves as the culmination of your preclinical education and represents your transition from preclinical to clinical training. The exam is transitioning to a pass-fail format “no earlier than January 1, 2022.” However, at present, how you score is often a primary factor used by medical school deans and residency program directors to decide if you can contend for a slot in one of the more competitive specialties or top programs. It’s big, it should be taken seriously, and its outcome can have lifelong consequences. Lawyers have the bar, doctors have Step 1.
Does this mean that you should panic during exam preparation? No! This exam is not for the faint of heart, but you will become familiar with its format and question style throughout your preclinical courses by means of NBME exams, question banks, and First Aid to the USMLE Step 1. If you take the time to develop good test-taking habits, focus during early course work, and decide how YOU best learn and retain information, you can conquer this test and get a fantastic jump start on your career.
Below is a synopsis of the Step 1 format and structure. While changes may be on the way for this test, the overwhelming likelihood is that the format of this exam will largely stay unchanged.
What is the USMLE Step 1?
The United States Medical Licensing Exam (USMLE) Step 1, most commonly referred to simply as “Step 1,” is the first of three national licensing exams that physicians must pass to practice independently. Step 1 is taken at the completion of pre-clinical training, usually around the second year of medical school. Step 2 is taken by fourth-year medical students prior to graduation, and Step 3 must be completed before the end of PGY-2 of residency. All three exams are taken at a Prometric testing center, which is a test-taking facility that ensures that exam administrations are standardized and secure.
Step 1 is the first test that distinguishes physician candidates from other health sciences fields. It does this by asking the physician candidate to bridge clinical and pre-clinical scenarios via multi-step questions, which require the synthesis of a “most likely diagnosis” and the knowledge of its basic underlying disease mechanisms. Hence, on this exam you are a literal “doctor on paper.”
In addition to its guidance of candidates in rudimentary clinical thought, Step 1 is also the only standardized exam for which the scores are consistently available for every residency candidate, which makes it a powerful threshold and benchmarking tool for residency directors hoping to screen their applicant pool. Currently, Step 1 score thresholds are often used by top programs in more competitive specialties to artificially trim down the applicant pool. Even top applicants with poor Step 1 scores may be omitted from a program’s consideration.
In the impending age of pass-fail scoring, a Step 1 failure is likely to be devastating to a residency applicant. Therefore, the onus to prepare for the exam properly will not change as the exam evolves.
Exam Content and Structure
Step 1 is an eight-hour exam that is subdivided into seven blocks of up to 40 questions each. You can take up to an hour per block, which means that on average each question should only be considered for about a minute and a half. If you finish a block early, any time saved can be “banked” for additional breaks above the 45 minutes available at the start of your exam. Although you cannot pause the exam while currently in a block, you can take breaks of any length that you’d like up to your maximum break time in between any blocks that you choose.
The USMLE provides a rough breakdown of the exam by organ system, competency, and discipline here. A variety of concepts are tested throughout the exam, including physician communication, biostatistics, and gross anatomy. However, around half of the exam is classified as pathology, suggesting a focus on disease states and their underlying mechanisms. An exhaustive concept list is provided by the USMLE here. However, it is inadvisable to study off of this list alone, as it weighs all concepts equally and does not permit appropriate selection and distillation of “high yield” concepts, which is done more proficiently through First Aid to the USMLE Step 1 and question banks.
A major advantage of this exam is the flexibility that it provides for self-directed breaks. This lets you plan and practice your test-taking pace, and know that it can be applied during the real exam. Bring extra food for breaks! A tactic I used to use was to buy three bagels with my favorite toppings to store in my testing locker. Each of the three breaks I planned for was bagel time – nothing better than a little comfort food and carbo-loading mid-exam. Everyone relaxes differently, but definitely give some thought as to how you’ll break. With seven fast-paced blocks, everyone will deal with test fatigue of some sort.
How Many Questions are on the Exam?
A total of 280 questions are on the exam. This total includes non-scored “experimental” questions, which are not distinguished from the scored official questions. The exact number of unscored questions is not disclosed by the USMLE, although it has been speculated that roughly 25% of each exam is experimental (or 80 questions per test) . Experimental questions are being benchmarked for future iterations of the test, and are therefore not calculated into your exam score. That means that you shouldn’t fret if you don’t know the answer to every question – maybe that one was experimental!
How Long Do I Need to Study for the Exam?
It’s impossible to totally cover all of the material that will appear on Step 1 while studying. The material is too voluminous and dense. Instead, we must rely on high-quality question banks and review books to distill material into “high yield” silos for us. An example of high yield selection can be seen in microbiology. Rather than having to memorize every aspect of every parasite, worm, virus, and bacterium, the high yield approach permits conceptual highlighting of those aspects of microbes most likely to be tested. Don’t memorize every viral structure, just understand “key” RNA and DNA viruses. You only have finite brainpower and finite time, so don’t waste it!
How long it takes for you to process all of that test-relevant information relies on a few factors:
How hard you studied during preclinical classes and how well you did on the NBME exams. While the NBME should not be used as a finite indication that you will pass Step 1, it is similarly formatted and necessitates similar test-taking strategies. It also highlights similar high yield material to that found on Step 1. So while resting on your NBME scores is inadvisable, using them as a bellwether to indicate the need for future focus is very useful when planning your study strategies.
How you learn. Flashcard “crammers” might build up a test knowledge base faster than people who only learn when they backwards-derive each concept from its basic mechanistic level to clinical fact. However, cramming is less likely to produce long-term retention, so creating a long-term study schedule that “peaks on test day” is crucial.
How confident you are. You GOT THIS! This test is important, but so was your MCAT and you had to have done well on that to be accepted into medical school in the first place. Confident examinees will score better; albeit, confidence during an exam and overconfidence in preparation are completely different issues. You should be prepared to be humbled by the preparation process, but in turn approach the exam confidently.
Top 3 Things You Need to Know If You’re Taking the Exam
Fatigue is real. You will get tired. How you plan for and manage your fatigue will heavily influence your ultimate score. I managed fatigue by planning my snack breaks, ensuring that I never took more than two sections in a row, and that I always had something to eat before going back. Colleagues of mine took a short walk to reset their minds. Know yourself, know how you recover from fatigue, and embrace it on test day.
Worst case, you can push the test back. Step 1 is offered on a rolling basis, and can be pushed back if you deem your preparation inadequate. I pushed my Step 1 back by six days because I felt mentally unprepared and made a slight adjustment to my study approach. I had the jitters and needed to get rid of them, so bought myself the time I needed to recalibrate – it wasn’t a long extension, but to me it was an eternity. On my new test date I showed up calm and happy. I am confident that rescheduling my exam improved my score.
Smile at the end, it’s OVER! 294 or 194: either way, a score between those numbers is a pass, and in 2022 your score above a passing mark will truly be irrelevant. Smile, celebrate, and move forward. You’re going to be a doctor, after all!
Author: Mitch Fourman, MD, Orthopaedic Surgery Resident, University of Pittsburgh