What to Know About the USMLE Step 1 Exam

The USMLE® Step 1 is the first of three exams taken by all medical students in order to become a licensed physician in the United States. The aim of the test is to assess whether students can apply principles of basic sciences to the practice of clinical medicine. As the only standardized measure of all students, performance on the USMLE® Step 1 is an extremely important factor for residency applications. Here’s what you need to know about the exam.

Format of the Exam

The USMLE Step 1 is a one-day exam, taken in one eight-hour sitting. The test is computer-based, consisting of seven sections of up to 40 multiple-choice questions, for a total of 280 questions. One hour is allotted for each section, which computes to approximately 90 seconds per question.

The exam is administered at monitored testing centers, and test-takers cannot bring anything into the exam room. 45 minutes are formally allocated for personal breaks during the eight-hour period, and an additional 15 minutes may be included if the test-taker chooses to skip the optional 15-minute tutorial at the start of the exam.

Registering for the Exam

US and Canadian medical students can register for the USMLE Step 1 Exam through the NBME website. Students from outside the US and Canada should register for the USMLE through the ECFMG website. The exam is scheduled by appointment at monitored testing centers year-round. The cost to register for the USMLE Step 1 Exam is $630 for US and Canadian students (NBME), and $940 for students from outside the US and Canada (ECFMG).

Topics Covered

The USMLE Step 1 tests understanding of basic science principles in the context of clinical practice. These basic science topics include biostatistics, behavioral sciences, biochemistry, immunology, pharmacology, and microbiology. These foundational topics are assessed in conjunction with clinical knowledge in anatomy, physiology, and pathology.

While some questions assess simple definitions, most questions aim to test your ability to organize facts and think through clinical scenarios. As such, students should be prepared to interpret graphs (e.g. pressure volume loops), radiographic imaging (e.g. MRI scans), analyze histopathological specimens (e.g. biopsy findings), and identify physiological and pathological mechanisms. These questions will often involve “two leaps” of reasoning. For example, a question stem may provide clinical symptoms requiring identification of a most likely diagnosis (the “first leap”), but the answer choices will then ask students to identify the correct pathological cause or treatment of the diagnosis (the “second leap”), as opposed to simply picking the diagnosis itself.

When to Take the Exam

The USMLE Step 1 Exam is commonly taken between the second and third years of medical school in a traditional four-year curriculum. This is generally after the completion of foundational sciences, and prior to the start of core clinical clerkships. However, some medical schools have altered this schedule in favor of students taking the USMLE Step 1 after the completion of core clinical clerkships. Students should be familiar with their home institution’s policies and curriculum to determine when they should take the exam.

Scoring of the Exam

Although USMLE does not disclose how scores are calculated, USMLE Step 1 scores theoretically range from 1 to 300. As of 2018, the minimum score needed to pass is 194 (USMLE). In 2017, the average score among US and Canadian first-time test takers was 229, with a standard deviation of 20 (USMLE). It is believed that each test taker’s final score is adjusted relative to the performance of other test takers, with weighting on a per-question basis. In simple terms, getting a “hard” question wrong that most examinees answer incorrectly will penalize your score less, as opposed getting an “easy” question wrong that most others answer correctly.

Scores are usually released on Wednesdays, three to four weeks after completing the exam. If a student receives a failing score, they may retake the exam up to three times within a 12-month period, until they achieve a passing score.  However, students who receive a passing score may not retake the exam to raise their score (USMLE).

Preparing for the Exam

Due to the importance of the exam, many medical students begin preparations for the USMLE Step 1 far in advance. Here’s a few pointers from our team.

1. Plan early. Most students spend at least 6 weeks full-time and up to a year part-time in order to prepare for the exam, depending on their background and familiarity with standardized exams. Make a study schedule and acquire necessary books/resources well ahead of your dedicated study period.
2. Take practice exams. The NBME provides comprehensive self-assessments that closely emulate the questions and computer interface of the actual exam. These practice exams can help you gauge progress, help you set realistic targets, and identify problem areas.
3. Focus on your weaknesses. Every student has a limited amount of time to study. Identifying weak areas to intensify review can yield more fruit than an unfocused approach.
4. Use Question Banks. Learning using questions not only reinforces knowledge, but also builds familiarity with clinical vignettes and question types. Many question banks exist, but the most widely used is UWorld’s Step 1 Qbank.
5. Use Image Learning. Visual mnemonics and memory palaces are an important tool for organizing and retaining vast amounts of information. Pixorize’s videos covering biochemistry and genetics are a powerful asset for students seeking to strengthen their grasp of basic sciences.

Studying with Pixorize

Pixorize makes beautiful visual mnemonics for biochemistry and basic sciences. Our short videos and ultra-cohesive story lines are used by thousands of students to master high-yield topics like biochemical pathways, vitamins, and more.

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