Ultimate Guide to the USMLE Step 1 Exam in 2021

What is the USMLE Step 1?

The USMLE Step 1 exam is the first of the United States Medical Licensing Exam stages (also known as ‘the boards’). Physicians with an MD degree are required to pass these exams in order to practice medicine in the United States. The Step 1 exam assesses your ability to provide safe and effective patient care. It’s notoriously tricky and often affects your future options for residency. Many experts say there is no detail too small for Step 1.

USMLE.org states that the Step 1 exam assesses “whether you understand and can apply important concepts of the sciences basic to the practice of medicine, with special emphasis on principles and mechanisms underlying health, disease, and modes of therapy”.

In order to pass, you’ll need to prove a foundational knowledge of the safe and ethical practice of medicine, as well as your ability to solve problems using basic scientific understanding. To dominate this exam, an in-depth understanding of the pathophysiology, epidemiology, semiology, and management of numerous disease entities is critical.

What is the passing score for USMLE Step 1?

Your USMLE Step 1 result is reported as a binary pass/fail, alongside a 3-digit score, ranging between 1 and 300. The passing score is 194, a slight increase from 192 in 2017. Despite the reputation of the USMLE Step 1 as one of the world’s most difficult exams, US and Canadian candidates secured a 94% pass rate in 2018.

Is the USMLE Step 1 Score Changing to a Pass/Fail Result?

On February 12th 2020, co-sponsors of the USMLE Program, the FSBM and NBME®, announced several important policy changes regarding USMLE eligibility and score reporting.

The most notable amongst these changes is that the USMLE Step 1 exam will no longer be scored as a 3-digit numerical score. This change will be implemented no sooner than January 2022. Read about these important changes in our USMLE Pass/Fail Score Blog

What is a good Step 1 score?

In 2018, US & Canadian candidates achieved a mean score of 230, with a standard deviation of 19. That means that around two-thirds of these candidates scored between a 211, and a 249. You can read more about how scores are calculated in the Examination Score Interpretation Guidelines from the USMLE.

USMLE Step 1 scores can have a direct impact on your residency choices later on. Some residency programs can be very competitive, such as dermatology, plastic surgery, otolaryngology, orthopedic surgery and neurosurgery. Fellowship programs are also inclined to use a resident’s Step 1 score as a primary indicator of past performance, especially more competitive fellowships such as gastroenterology, oncology, cardiology, and surgical fellowships. For example, according to the National Resident Matching Program, the mean score for candidates who matched in Orthopedic Surgery in 2018 was 248.

While you do need to ace the exam to secure a tough residency, do remember that your Step 1 score is one of many factors which will be considered when you apply. The fundamental knowledge obtained in this process will also set you up for success during the clinical years and Step 2.

When should you take USMLE Step 1?

Scores are assigned in the context of a cohort of test-taker scores; however, the USMLE also uses past cohorts as controls. This means that the idea of strategizing to take the exam during “the time of year that is easiest to score best” is likely invalid. You should not worry about this issue but rather focus on the optimal time based on your individual study plan (usually set by your institution’s schedule).

How long does it take to get your Step 1 score after the exam?

Results are typically available three to four weeks after your test date. However, it’s not unheard of for test results to be delayed by up to eight weeks. In most cases, when there is any national US holiday, expect a delay of a week. Once your score is available, you will be emailed instructions to access your USMLE score report, which is available for one year. After that year is up, you will only be able to access your scores via an official USMLE transcript, which is available for a fee. It is advisable to save a pdf version of this report as this will be required in the future for applying to residency (ERAS).

USMLE Step 1 Exam Format

The Step 1 exam is a computer-based test taken in a single, eight-hour day. The test includes seven sections (blocks) of up to 40 questions, totaling up to 280 questions. One hour is allotted for each section and each block is made up of sets of random questions rather than linking themes.

Test takers are provided 45 minutes during the exam for personal breaks. This may be used however you like during the exam (intermittent short breaks between sections vs. longer breaks between a few of the sections). Be warned – you can only take non-electronic earplugs into the exam room, no bags, phones or even jackets allowed!

USMLE Step 1 Question Types

All of the Step 1 questions are in a multiple-choice format, in a style known as Single Best Answer (SBA). This means you must read a clinical scenario regarding a single patient, known as a vignette, then select the one best answer out of at least five potentials. Answer choices are listed in alphabetic order. Test writers are advised to keep question answer length similar in character count. Check out these sample questions from the USMLE.

Some questions may contain oscillation media, in which various heart sounds or lung sounds are heard. Keep in mind that these media questions may be completely normal and the answer to the question is determined based on the written vignette. Other questions may give lab values, EKG, imaging, or Pathology Slides to review.

In each block, you will experience a single linked question – where a follow-up question will be presented regarding the same patient.

USMLE Step 1 Syllabus

The USMLE Step 1 exam is based on an integrated content outline, which organizes content according to general principles and individual organ systems. Test questions are classified in one of 18 major areas, depending on whether they focus on concepts and principles that are important across different organ systems or within individual organ systems. In most instances, knowledge of a normal process is evaluated in the context of a disease process or specific pathology.

The systems with the largest weighting are General Principles (13-17% of the total exam), Behavioral Health & Nervous Systems/Special Senses (9-13%), Reproductive & Endocrine Systems (9-13%) and Respiratory & Renal/Urinary Systems (9-13%).

Here’s a brief explanation of the exam topics from high-scorer Derek Kong, who achieved a 268 on his Step 1 exam. Derek is a Pastest contributor, now specializing in ENT / Head and Neck Surgery at the renowned Mount Sinai Hospital in New York.

The topics tested on Step 1 are subdivided by organ system, or by discipline. For example, organ systems include cardiovascular, GI, neurology and reproductive. Within these systems, questions may pertain to normal physiology, pathophysiology, or pharmacology. There are some disciplines that don’t neatly fit into the system subdivisions; such as biochemistry, genetics, autonomic pharmacology and social sciences. These topics may be tested separately, or integrated into multi-disciplinary questions pertaining to specific organ systems.

Although the scope of material assessed on Step 1 is broad, it is limited to this finite number of topics.

This is an excerpt from our Podcast Series entitled USMLE 101: Maximize Your Step 1 Score.

What does High-Yield Mean?

You hear it all the time – “This is really high-yield information!”, but what does that really mean? Step 1 is an extremely detailed exam which dives into the minute details of clinically relevant topics. There are inherently details within each topic which have historically been repeatedly tested. Individuals who have invested a significant amount time in reviewing practice tests, taking the steps, and reviewing most of the practice materials recognize this recurrent, “high-yield” information. Test-review organizations (questions banks, review books) spend a tremendous amount of time and resources to generate content with the highest probability to be tested.

Focusing on this high-yield information will give you the biggest bang for your buck; however, I like to tell students that there is no detail too small for Step 1. This is why having a variety of high-yield resources is advantageous.

How long does it take to study for the Step 1 exam?

A guide from the AOA Honor Society at the Sidney Kimmel Medical College, Jefferson, answers this question well – your Step 1 study really starts on the first day of medical school, as the exam tests the knowledge that you accumulate in your first two years.

It is common practice for USMLE Step 1 candidates to take up to five or six weeks of dedicated study time – with 8-12 hours of exam prep every day. US Med students typically have between 45 and 90 days between second year final exams and the USMLE Step 1 exam – which is used for dedicated study. It’s important to ensure that you also schedule in downtime to relax, or risk negative impacts on your mental health and wellbeing.

How to Study for the Step 1 Exam

It’s never too early to begin your preparation for the Step 1 exam. From day one of medical school, you’ll be learning topics and concepts that will be tested in the Step 1 exam, and you can support your learning in a variety of ways.

Many students study using the popular First Aid for the USMLE Step 1 textbook, alongside a Qbank with integrated references. It is advantageous to use a variety of resources, such as question banks and First Aid, to supplement your class content. In doing so, you will synthesize information rather than just memorize it. In the first few months of medical school, you’re not going to be ready to answer USMLE-level questions, which is why we recommend utilizing the Pastest Progressive System, which helps you to scaffold your learning alongside your school’s curriculum. It builds your foundational knowledge, pattern recognition and critical thinking skills, teaches you to think like a clinician, and prepares you to tackle exam-style questions much earlier than traditional study methods.

Leading up to their dedicated study period, students typically work through a High-Yield USMLE Step 1 Question Bank – not only to refresh their knowledge of key exam concepts, but also to develop their exam technique. The Step 1 exam is a marathon, not a sprint, and candidates need to be able to answer a question every 90 seconds just to get through the whole exam. In the final weeks before the exam, most candidates work through the UWorld question bank, and the NBME Self-Assessment exams.

How do you register for the USMLE Step 1 exam?

For US students:

For students and graduates of LCME-or AOA-accredited medical programs in the US or Canada, you will need to obtain a USMLE identification number. Applications are made through the NBME (the National Board of Medical Examiners) on NLES (NBME Licensing Examination Services). You will need your SSN and medical school information for the online application. After registration, you will receive your USMLE ID and password via email within one business day.

During the registration process, you will be asked to designate a three-month window, during which your registration permit will be valid. You must schedule your test date within this three-month period. Note that additional fees may apply if you need to extend this period, or change your test date.

The USMLE Step 1 exam is administered by a third-party company, Prometric. As Prometric administers many exams in addition to the USMLE, test dates and preferred locations fill up quickly, so ensure that you secure your test date well ahead of time. When your registration has been processed, NBME will then e-mail you with your scheduling permit to confirm the three-month window in which you can schedule your exam date.

For International Medical Graduates (IMGs):

If you are a student or graduate of a medical school outside the US or Canada, to take the USMLE Step 1, you will first need to apply for ECFMG Certification. To be eligible for ECFMG Certification, your medical school must be listed in the World Directory of Medical Schools. You can apply online and the application costs $135. The process can take up to six weeks so it’s advisable to get it done well in advance of when you want to start studying for USMLE Step 1.

How much does The USMLE Step 1 cost?

According to the ECFMG website, the examination fees for USMLE Step 1 have risen to $975 for each exam registration in 2021.

Prometric also charges a $50 fee for examinees to change their testing appointment within 31 days of their test date – there is a higher fee if you change your appointment five days or fewer before the test date.

If you are an International Medical Graduate (IMG), it costs $975 to take the USMLE Step 1 with a minimum surcharge if you’re taking the exam outside the United States. This surcharge increased to $180 in 2021. There are also additional fees – some quite high – for changing the date or location of your exam, as well as translation fees if translation is required. You can see the full list of charges on the ECFMG website.

Where and when can you take the USMLE Step 1 exam?

Most cities in the US will have at least one testing center for the USMLE Step 1 – New York, for example, has eight test centers. There are also test centers in major cities in countries around the world. To find your nearest test center and schedule your examination, visit the Prometric website. It’s useful to note that the Step 1 exam is not offered during the first two weeks of January or on major local holidays.