Your strategy for how to study for USMLE Step 1 should include more than content review. To prepare for this challenging, 8-hour exam, you must know the exam format and what to expect on the test day. In this blog, you will find out about USMLE Step 1 eligibility requirements and exam content, read some sample USMLE Step 1 questions, and learn the strategies that will help you ace your exam.
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What is the USMLE Step 1
The United States Medical Licensing Examination (USMLE) Step 1 is a computer-based exam available at Prometric Test Centers around the world. It evaluates whether you understand and can apply key concepts of the basic sciences that are fundamental to the safe practice of medicine, with specific emphasis on principles and structures underlying health, disease, and types of therapy. While the USMLE Step 1 exam evaluates your theoretical preparedness for supervised medical practice, it also provides you with an opportunity to get ready for the OSCE components of USMLE examinations. You must pass Step 1 to move on to the next USMLE Steps.
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USMLE Eligibility Requirements
Typically, students of the US medical schools take Step 1 after the first two years of medical school. Step 2 Clinical Knowledge (CK) and Clinical Skills (CS) are usually taken after the 3rd year (clerkships). You may take USMLE Step 1 and Step 2 CK in any sequence if you are an international medical graduate (IMG). To be eligible to take the USMLE exams, you must meet one of the following eligibility requirements at the time you apply and on the day of your examination:
Keep in mind that you may not take the same USMLE Step or Step Component more than 6 times, including incomplete attempts. All attempts are counted towards the limit, regardless of when the examinations were taken. If you pass a Step or Step Component, you are not allowed to retake it, except to comply with a time limit imposed by a US physician licensing authority for completion of all Steps or by another authority recognized by the USMLE program. If you have already been licensed as a physician by a US medical licensing authority based on other examinations, such as the Federation Licensing Examination (FLEX), the NBME certifying examinations, or the National Board of Osteopathic Medical Examiners COMLEX-USA, you may not be eligible to take the USMLE. If you wish to re-take a failed examination Step, you may not attempt the same Step or Step Component more than three times within 12 months. Your fourth and subsequent attempts must be at least 12 months after your first attempt and at least six months after your most recent attempt at that examination. This includes incomplete attempts.
Eligibility Period and Scheduling Your Test Date
When you apply for the examination, you must select a three-month eligibility period during which you plan to take the USMLE Step 1, for example May to July. Once your registration is complete, a scheduling permit with your eligibility period will be issued. You will receive an email with instructions for accessing your permit. After obtaining the scheduling permit, you may visit the Prometric website to schedule a test date that suits your availability. Scheduling is typically not available for more than six months in advance. You can reschedule your test date within your eligibility period, but you must pay a fee if you reschedule during the 30 calendar days before your scheduled appointment. If for some reason, you cannot test within your eligibility period, you must contact the organization that registered you for your exam to ask for a one-time contiguous eligibility period extension. You will be charged with a fee for this service. If you fail to take the exam within your original or extended eligibility period, you must reapply by submitting a new application and fee(s). Be aware that fees are non-refundable and non-transferable. Important: print out your scheduling permit and keep it in a safe place. You must bring it with you to the test center on the day of your test. You will not be allowed to take the exam without your scheduling permit.
Once you've gotten your permit, you may schedule your test online at www.prometric.com for any available test date that is within your approved 3-month eligibility period. Not all Prometric centers are open on weekends, and USMLE exams are not necessarily offered every day the centers are open. Please note that May through July is one of the busiest periods for these testing centers, so plan ahead.
USMLE Step 1 Format
Step 1 consists of a series of multiple-choice questions (MCQs) that was prepared by the examination committees composed of faculty members, teachers, investigators, and clinicians with recognized prominence in their respective fields. Step 1 is a one-day examination. It is divided into seven 60-minute blocks and administered in one 8-hour testing session. The number of questions per block on a given examination form may vary but will not exceed 40. The total number of items on the overall examination form will not exceed 280. So, you will have about 1.5 minutes to answer each question. During each block, you can answer questions in any order, go back and review questions in the block and change your answers. Once you complete and exit a block or the time for that block expires, you may no longer go back and change your answers. Some questions may include pictures and audio, such as histology, gross pathology, CT images, or heart sounds.
USMLE Step 1 includes only single best answer questions, i.e. the traditional multiple-choice format. The questions consist of a statement or question, followed by three to eleven response options. You are required to select the best answer to the question. Keep in mind that there may be responses that are partially correct, but there is only one best answer. If you’re not sure about the correct response, you should still choose an answer you deem the most likely to be correct. You are not penalized for guessing, but any unanswered questions will be marked as incorrect. Tip: you should always save several minutes at the end of examination for any skipped questions to at least attempt an educated guess. Just by eliminating 1 or 2 choices, your chances of guessing correctly improves, but any omitted question is an automatic incorrect. So, take a guess even if you don't know the answer!
After you start taking an examination, you cannot cancel or reschedule it. If you experience a computer issue during the test, you must notify the test center staff immediately. The testing software is designed to restart the test at the point where it was interrupted without loss of time. The test session ends when you have started and exited all blocks or the total test time expires. You will receive a notice during checkout that you have appeared for the test. If your test is scheduled for multiple days, be sure to bring a copy of your scheduling permit with you each day or you may not be permitted to test. If you experience any technical issues that do not allow you to complete your examination, please send a written description of the incident to Test Administration Services at the NBME. Test Administration Services must receive your notice within 10 days of your testing date, or it may not be possible to fully investigate your concerns. Your correspondence should include your name, your USMLE ID number, the examination name (Step 1, 2 CK, or 3), the date of administration, and a message with a detailed description of the difficulty experienced. Please allow at least 15 business days for your report to be investigated and evaluated. You will receive written notification of the investigation results. If you start the examination but do not complete it for reasons other than a technical problem or expiration of time, you should promptly write to Test Administration Services explaining in detail the reasons you did not finish the examination. The attempt may appear as an incomplete on your USMLE transcript.
Your USMLE Step 1 test session is scheduled for a fixed amount of time, and the computer keeps track of the time allocated for each block and breaks. At the start of the testing session, you have a total of 45 minutes of break time for authorized breaks and computer transitions between blocks. Authorized breaks include any time you spend between test blocks, whether you remain at your seat or leave the testing room. If you complete the tutorial or other testing blocks early, the remaining time will be added to your total break time. Once you begin a testing block, you may not leave the room except in the event of an emergency. If you leave the room for a personal emergency and you are not on an authorized break, the block and clocks will continue to run, and the test center will report the incident to the USMLE program. Additionally, the unauthorized break screen, described in the examination tutorial, will appear on the monitor after a period of inactivity. After the unauthorized break screen appears, you will need to enter your CIN to continue with the examination. Each time you leave the testing room, you are required to sign out and sign in when you return using your identification each time. If you exceed your allocated or accumulated break time, the excess will be deducted from your total testing time. Use the time summary feature, which will be explained in the tutorial on your test day, to keep track of your time.
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USMLE Step 1 Content
Please review this content outline before you start studying for the USMLE examinations. This guideline organizes exam content according to general principles and individual organ systems. All exam questions are assembled in one of the 18 major areas, depending on whether they focus on concepts and principles that are important across organ systems or within individual organ systems. Sections that focus on individual organ systems are subdivided according to normal and abnormal processes. In most cases, knowledge of normal processes is assessed in the context of a disease process or specific pathology. Around 10%-20% of exam questions evaluate knowledge of normal processes in this way. Remember, not all topics listed in the content guideline will be included in every USMLE examination. However, overall content coverage is comparable among the various exam forms that will be taken by different candidates for each Step.
USMLE Step 1 also assesses your readiness to perform physician tasks and responsibilities. Each test question evaluates one of the following competencies:
Please review a detailed outline of the physician tasks and competencies here.
Additionally, each Step 1 examination covers content related to traditionally defined disciplines and interdisciplinary areas listed below:
Sample USMLE Step 1 Questions
Competency: Communication and Interpersonal Skills
Content Area: Social Sciences
A 22-year-old man comes to the clinic to discuss the results of an HIV immunoassay done 1 week ago. At that time, he was also diagnosed with syphilis, and intramuscular penicillin was administered. He has no other history of serious illness and no known drug allergies. He takes no other medications. He had never previously undergone HIV testing. He has had sexual intercourse with six sexual partners in his lifetime; they have used condoms inconsistently. Vital signs are within normal limits. Physical examination shows a resolving, painless chancre over the penis. He is informed that HIV immunoassay results are positive. Which of the following is the most appropriate statement by the physician to the patient at this time?
(A) “At this time, we recommend antiretroviral therapy for all HIV-infected patients. This needs to be taken consistently for the rest of your life. Are you ready to start therapy today?”
(B) “I noticed that you had never been tested for HIV before last week, although you were at high risk for infection. Why is that?”
(C) “Pre-exposure prophylaxis is very effective in preventing HIV infection. Had you ever considered using it?”
(D) “What are your thoughts and feelings about this HIV test result?”
(E) “You must be shaken by this diagnosis but understand that we have effective treatment for this that can enable you to lead a normal life.”
Competency: Medical Knowledge/Scientific Concepts; Patient Care; Diagnosis; History and Physical Examination
Content Area: Nervous System and Special Senses
A 31-year-old woman is brought to the emergency department 45 minutes after sustaining injuries in a motor vehicle collision. Physical examination shows tenderness to palpation of the right upper extremity. An x-ray shows a midshaft fracture of the right humerus. The physician wants to assess the integrity of the radial nerve, but the patient has severe pain with movement of the upper extremity. If this patient has sustained damage to the radial nerve, altered sensation to a pinprick of which of the following areas would most likely confirm the diagnosis?
(A) Anterior medial surface of the forearm
(B) Palmar surface of the index finger
(C) Palmar surface of the small finger
(D) The posterior lateral surface of the hand
(E) The posterior surface of the small finger
Competency: Practice-based Learning
Content Area: Biostatistics
A study is designed to evaluate the feasibility of acupuncture in children with chronic headaches. Sixty children with chronic headaches are recruited for the study. In addition to their usual therapy, all children are treated with acupuncture three times a week for 2 months. Which of the following best describes this study design?
(B) Case series
(E) Historical cohort
(F) Randomized clinical trial
How to Study for USMLE Step 1
Let's go over some USMLE Step 1 study strategies that will help you ace this exam!
Take Practice Tests. Start by taking practice tests. The AAMC offers a series of USMLE practice tests, which are in fact old tests that accurately reflect and predict your scores. Many students use UWorld as the source of practice tests, although there are numerous others, like Kaplan, USMLE Rx, etc., that may not be as challenging. Taking such tests will help you identify the areas of knowledge that need improvement. Most students have certain subjects they struggle with. As you’re taking the practice tests and see yourself struggle with certain topics, make sure to include those disciplines and content in your study plan.
Create a Study Plan. Try to create a schedule for everything you will cover throughout the week – make it as detailed as possible. This will help you see how much content you can study in a day. Make sure that you set achievable goals by indicating the pages you will review and the type of questions you will practice with. It is normal to readjust your study schedule as you begin to review the content. Remember, you need to be mindful of how you spend your time, otherwise you might not be able to go through all the necessary material.
Active Study Strategies. Use active, rather than passive, study strategies to comprehend and retain information. Write down any information, question, or content you struggle with to increase your understanding of the subject. Try explaining concepts to friends and family. When you practice with test questions, do not read the responses right away. After reading the item, try to come up with your own response and then choose the one response closest to yours.
Don’t Ignore Any Subject. You might think that some subjects are less important to review, but if you avoid reviewing some easy points in something like Biostatistics, you may jeopardize your USMLE Step 1 performance. Do not dismiss any subject matter and let the gap in your knowledge grow. Reviewing simpler topics, such as behavioral science, certain biochemical pathways, biostatistics, to name a few, could mean getting the score you want. This is very key. You can gain many easy points simply by spending a few extra hours reviewing the concepts in biostatistics and behavioral sciences. These disciplines' questions on the exam tend to be simple, and just reviewing the content will be sufficient for answering the questions. However, if you ignore these content sections, these questions are freebies that you end up losing out on. So, make sure you do not completely dismiss any knowledge areas or disciplines when you create your study schedule.
Sync Your Schedule with the Exam Schedule. Wake up every day at the same time you will need to wake up on the day of the exam. Try to coordinate your day with the exam schedule, i.e. do not take naps between 8 am and 5 pm, otherwise your body will require a nap during the exam. Get into a habit of waking up early, so your body will find it easier to fall asleep at night. Get a sufficient amount of sleep – rest makes you a more efficient learner. This exam is a long and strenuous process – you need to be mentally and physically ready for it.
Review Keywords, Phrases, and Concepts. As you get close to your exam date, it is not wise to start cramming new material or spending too much time on content you know quite well. Look over your summary notes one more time. When you have only a week or two left before the exam, try to focus on retaining essential information. Recall the material by yourself, rather than simply reading over it again. After several weeks of study, you already know the content, you just need to train yourself to access it when you need it. Doing practice tests is a good way to reinforce your recollection skills.
Visit the Prometric Center. If you get the chance, visit the Prometric Test Center where you will be taking the exam. It will be indicated on your exam entry ticket. This way, you will know how to get there and how much time you should plan for your commute. Find the parking lot and see what the computer set-up is like. Prometric centers actually allow students the opportunity to take a practice USMLE exam for a small fee. It is not a full-length exam, but a 3-hour practice trial. You can use your own computer and equipment. If possible, I would strongly recommend you take this opportunity to help you feel more comfortable during the actual test.
Take a Day Off. The day before your test should be a day of relaxation. Do not study and have some fun. For example, go for a walk, listen to some of your favorite music, go see a movie, or visit some friends. Wake up early and go to bed on time. You need to be rested on the test day.
1. How do I apply for USMLE Step 1?
To apply to any of the USMLE Steps, you must submit an application through your registration entity. Students and graduates of LCME or AOA accredited programs should apply for Step 1, Step 2 CK, and Step 2 CS by following the instructions on the NBME website. Students and graduates of medical schools outside the US and Canada should apply for Step 1, Step 2 CK, and Step 2 CS by following the instructions on the ECFMG website.
2. How much does USMLE Step 1 cost?
The USMLE Step 1 and Step 2 Clinical Knowledge (CK) cost $949 for each exam registration.
3. Is there a limit on the number of times I can take Step 1?
You can take a Step or Step Components up to 6 times in a lifetime. You may not attempt the same Step or Step Component more than three times within 12 months. Your fourth and subsequent attempts must be at least 12 months after your first attempt and at least six months after your most recent attempt at that examination. This includes incomplete attempts.
4. Do the Steps have to be taken at particular points during my medical education and career?
You must pass Step 1 and Step 2 before you are eligible to take Step 3. Most students at LCME-accredited medical schools will take Step 1 at the end of their second year and Step 2 CK and CS in their fourth year. Step 3 is usually taken during the first or second year of postgraduate training.
5. How is my USMLE score reported?
At the moment, the USMLE Step 1 score is reported on a three-digit scale. The current minimum passing score for Step 1 is 194. However, the USMLE is currently working to change Step 1 scoring to a pass/fail system. You will receive notice of whether you passed or failed the exam. No actual score will be reported to you. The same scoring and quality control measures will continue to be applied. USMLE will continue releasing scores weekly (Wednesdays), with Step 1 scores generally released within 3-4 weeks of the test date. Check the official USMLE website for updates about this change.
6. What are some of the resources I can use to help me get ready for USMLE Step 1?
Typically, the highest yield resources are the First Aid for the USMLE Step 1 and Pathoma, a set of video lectures/pathology review. You can use UWorld as the primary source for practice questions. You should resist the urge to collect multiple review books or spend your study time bouncing back and forth from too many materials, as each review is structured differently, so this will not the best use of your time. The students that perform well typically find 2-3 main resources and stick with them until the end of their USMLE exams.
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