First Aid for the USMLE Step 1 2011

1. Understand the USMLE Step 1 Exam Format and Structure.

The CBT Step 1 exam consists of seven question “blocks” of 46 questions each (see Figure 1) for a total of 322 questions, timed at 60 minutes per block.

The exam is a computer-based test (CBT) comprising 7 blocks of 46 questions each, totaling 322 questions. Each block is timed at 60 minutes. You get a minimum of 45 minutes of break time, which can be increased by skipping the initial 15-minute tutorial or finishing blocks early.

The CBT interface includes features like highlighting, strikeout, searchable lab values, and a calculator. Questions are primarily one-best-answer, with a significant portion presented as clinical vignettes. Some questions may include media clips or sequential items.

Scoring is based on the total number of correct answers. You receive a pass/fail status and two scores (3-digit scaled score and 2-digit minimum passing score). Scores are typically released 3-6 weeks after the exam date.

2. Plan Your Study Strategy and Timeline Early.

Customize your schedule to your goals and available time.

Define your goals for the exam early, as this will influence your study intensity. Goals may range from simply passing to achieving a high score for competitive residency programs.

Create a realistic study schedule, typically spanning 5-7 weeks, factoring in your school's curriculum and personal commitments. Prioritize less "crammable" subjects like anatomy and pathology earlier, while saving more concise subjects like behavioral science and physiology for later review.

Maintain a healthy lifestyle throughout your preparation to avoid burnout. Ensure proper diet, exercise, and sleep. Avoid comparing your progress to others and focus on your own plan.

3. Choose and Utilize High-Yield Study Materials Effectively.

Focus on a few top-rated resources that suit your learning style—not on some obscure books your friends may pass down to you.

Select high-quality review books based on recommendations, reviews, and personal preference. Avoid using too many resources, which can be overwhelming. Supplement core review books with clinical review books to prepare for vignettes.

Start using review books early in your first year of medical school. Integrating them with your coursework makes them familiar and personalized by the time you begin dedicated Step 1 study.

Limit your reliance on textbooks and syllabi for dedicated review, as they are often too detailed or inconsistent with the exam's emphasis. Focus on concise, high-yield materials designed for boards preparation.

4. Master Test-Taking Strategies for the CBT Format.

Practice and perfect test-taking skills and strategies well before the test date.

Time management is crucial, with approximately 78 seconds per question. Practice pacing yourself during simulated exams to avoid running out of time.

Develop a strategy for approaching questions, such as identifying them as easy, workable, or impossible. Make your best guess on diffi cult questions and mark them for review if time permits. There is no penalty for wrong answers.

Be mindful of changing answers; while your first hunch is often correct, studies show that changed answers are more likely to be correct than incorrect. Avoid dwelling excessively on any single question.

5. Focus on High-Yield General Principles.

This high-yield material includes molecular biology, genetics, cell biology, and principles of metabolism (especially vitamins, cofactors, minerals, and single-enzyme-defi ciency diseases).

Master core concepts in Behavioral Science, Biochemistry, Embryology, Microbiology, Immunology, and Pathology. These principles form the foundation for understanding organ system pathology and pharmacology.

Pay special attention to frequently tested areas within these disciplines. For example, in Biochemistry, focus on metabolic pathways, enzyme defi ciencies, vitamins, and lab techniques. In Immunology, understand cell types, immune responses, and defi ciencies.

Utilize mnemonics and diagrams provided in review resources to aid memorization of key facts and associations. Recognize that not all memory techniques work for everyone.

6. Integrate Knowledge Across Organ Systems.

As you progress through each Organ System, refer back to information in the previous subsections to organize these basic science subsections into a “vertical” framework for learning.

Study organ systems by integrating knowledge from anatomy, physiology, pathology, and pharmacology. Understand how basic science principles manifest in clinical presentations of organ-specific diseases.

Focus on the classic signs, symptoms, and pathophysiology of major diseases within each system. Learn the mechanisms of disease and how they relate to altered physiology and the effects of pharmacologic interventions.

Use a "systems-based" approach during your review to connect concepts across disciplines. This helps build a more comprehensive understanding of disease processes.

7. Practice with Representative Questions and Simulate the Exam.

Simulate the USMLE Step 1 under “real” conditions to pinpoint strengths and weaknesses in your knowledge and test-taking skills.

Take practice tests early in your preparation to identify areas of weakness in both knowledge and test-taking skills. Use these results to guide your study plan.

Utilize high-quality question banks and practice exams that are representative of the Step 1 format and content. The NBME Comprehensive Basic Science Self-Assessment (CBSSA) is a good predictor of performance.

Simulate the actual CBT environment as closely as possible during practice tests, including timing and break structure. This helps you become comfortable with the testing conditions.

8. Address Special Situations (IMGs, Disabilities, etc.).

It is extremely important that you send in your application early if you are to garner the maximum number of interview calls.

International Medical Graduates (IMGs) must obtain ECFMG certification by passing Step 1, Step 2 CK, and Step 2 CS. Applying early for residency and obtaining US clinical experience and letters of recommendation are crucial.

Osteopathic (DO) medical students may consider taking both the COMLEX-USA Level 1 and the USMLE Step 1, especially if applying to allopathic residency programs. The exams differ in style and content emphasis.

Students with disabilities can apply for testing accommodations under the Americans with Disabilities Act (ADA). Early application to the NBME or ECFMG with proper documentation is required.

9. Prioritize High-Yield Pathology and Pharmacology.

The fundamental principles of pathology are key to understanding diseases in all organ systems.

Pathology is a cornerstone of the Step 1 exam, heavily integrated into clinical vignettes. Focus on the basic principles of infl ammation and neoplasia, as well as the hallmark characteristics and clinical presentations of major diseases.

Pharmacology is also high yield, requiring memorization of key drugs, their mechanisms of action, clinical uses, and important toxicities. Focus on prototype drugs and classic side effects.

These two disciplines are often tested together in clinical scenarios, requiring you to identify a disease and then recall its underlying pathology or appropriate pharmacologic treatment.

10. Familiarize Yourself with Key Behavioral Science and Biostatistics Concepts.

Behavioral science questions may seem less concrete than questions from other disciplines, requiring an awareness of the social aspects of medicine.

Understand the principles of epidemiology, including different study types (case-control, cohort, cross-sectional) and common biases. Be able to interpret measures like odds ratio, relative risk, prevalence, and incidence.

Master basic biostatistics concepts, including statistical distributions, hypothesis testing (Type I and II errors), confi dence intervals, and common statistical tests (t-test, ANOVA, chi-square).

Review medical ethics principles (autonomy, benefi cence, nonmalefi cence, justice), informed consent, confi dentiality, and common ethical dilemmas encountered in clinical practice.

11. Utilize Review Resources and Question Banks Wisely.

In selecting review books, be sure to weigh different opinions against each other, read the reviews and ratings in Section IV of this guide, examine the books closely in the bookstore, and choose carefully.

Consult the database of top-rated review resources (Section IV) to select books, question banks, and other materials that fit your learning style and budget. Don't feel pressured to buy every recommended resource.

Question banks are essential for practicing Step 1-style questions and identifying knowledge gaps. Use them to reinforce concepts and improve test-taking skills.

Commercial review courses can be helpful for some students, but they are expensive and require a significant time commitment. Consider them based on your individual needs and learning preferences.

Last updated: May 15, 2025