Let’s address the gigantic elephant in the room: no, you do not have to take the USMLE® Step examinations sequentially. 

Fearing how the ACGME merger would affect the application process as an osteopathic student, I decided to take both the COMLEX® and USMLE standardization examinations to cover all my bases. After taking the COMLEX, I felt it was necessary to postpone Step 1 to better prepare myself. 

But the question remained, “when exactly should I take Step 1?” After some reflection and reaching out to advisors and students who took it before me, I felt my best chance of success was to follow the unconventional route and take Step 2 before Step 1. Below are some of the pros and cons of my experience.

Pro: Bringing Clinical Exposure to Step 1

Studies have shown that experiencing something actually makes it easier to remember. 

For example, let’s take studying heart failure. Throughout medical school, we learn the signs of heart failure and how to treat it through textbooks and lectures. However, unless you have worked in a clinical setting before and have treated a patient with these signs yourself, you take the information at face value and understand it only in the abstract. 

After a  year of clinical experience, you’ll put this knowledge into practice, and you’ll more easily recall symptoms, pathophysiology, and medication effects on the day of the exam. In fact, as I was going through practice questions, many situations felt like second nature and I was able to make more educated guesses.

Con: Relearning/Cramming Subjects Not Covered During Clinical Rotations for Step 1 

Subjects like biochemistry, histology, and embryology seldom come up on the wards and clinical rotations. My biggest worry during my Step 1 dedicated period was having to take a lot of time to relearn everything. 

Surprisingly, most of the information comes back quickly. When I was going through practice questions, I still remembered topics like vitamins and some of the pharmacology overlap. In addition, there are a handful of resources available that tackle these subjects in an efficient and brief way.

If crunched for time, I would approach these topics in a smart way. Take biochem, for example. I can vividly remember, in my first year of medical school, the times I spent writing out the metabolic pathways on the blackboard, trying to remember every cofactor of the Krebs Cycle. However, I decided to put more emphasis on the diseases and enzyme deficiencies when I was studying for Step 1. Even though as medical students (and perfectionists) we want to know and understand absolutely everything, sometimes it’s best to sacrifice a couple of nit-picky details in favor of high-yield topics.

Pro: Having Another Year to Figure Out Your Weaknesses and Fine Tune Studying

Before my third year started, I reflected on my study habits during my dedicated period and pre-clinical years. By now, it was easier to identify which topics and areas I could improve on–for example, focus. I felt that during exams I would zone out and not be fully present. So, throughout my third year, I experimented with different resources and ways to improve on it: talking to a psychotherapist, meditation, jogging, and yoga. If your habits work in your favor, that’s alright too! Honing your techniques can still pay dividends personally and academically.

Con: Fatigue Studying for Step 1 and Step 2

After studying for Step 2 and due to the time constraints of my first M4 rotation, there was little leeway for me to take a break. By the tail end of my Step 1 study period, I was hitting study fatigue. This consisted of a tremendous lack of focus and retention no matter how much caffeine I consumed. 

To combat this, I had to make my days more varied and find new ways to stimulate my brain. One simple solution was to change my routine. So, for example, instead of waking up and answering practice questions, I would start by watching videos or review notes. After a set amount of time, I would reward myself by doing something fun: going on a jog, playing video games, or grabbing lunch with friends. Nota bene: I did have to be disciplined and cut off these activities at a reasonable time. Sometimes my 30-45 minute breaks stretched a little too long. 

There is no one way to approach exams. There are pros and cons to every situation, but what is most important is having the determination to commit to a plan. What we lose sight of is that our application is more than your score. Everyone can have a bad test day, and there are other areas of your application that will better represent who you are as an individual to residency programs. Continue the grind and remember that with each standardized exam, you’re one step closer to becoming a doctor.