Advice From a USMLE® Step 1 Test-Taker in the Era of Pass/Fail

Paulino Gárate - Apr 06, 2022

There’s no doubt that one of the best ways to prepare for the USMLE®s is by listening to the advice of those who have come before you. And since Step 1 turned pass/fail in January 2022, there are only a few brave students who can share their insights about what it’s like to sit Step 1 in this new environment. One such student is Paulino Gárate who recently passed his Step 1 exam and is now preparing for the USMLE Step 2 CK exam. 

From his unique position as a Step 1 test-taker in the era of pass/fail, Paulino offers valuable insights on: 

Read his interview with AMBOSS below to hear how he prepared for Step 1.

Do you think the USMLE Step 1 exam has changed much since becoming pass/fail? 

From my vantage point, I think that Step 1 has changed in a significant way, ever since the modifications that occurred in November 2020. Now we’re seeing a notable emphasis on topics that were not previously tested that often. For instance, now you can expect at least three to four questions on communication and interpersonal skills in most of the blocks. We’re also seeing more questions on patient-centered care, the health care needs of minority populations,  and patient-communication questions. 

In regards to biostatistics, instead of focusing on memorizing all the formulas, you should focus your attention on understanding the concepts, since now it’s seldom that you will encounter a simple question asking for sensitivity or specificity. I was overly worried about memorizing all the pharmacology, biostatistics, and physiology formulas and I got zero calculation questions. 

When I took the exam, I felt that it was tougher than I expected it to be. However, it was doable if you have solid knowledge and test-taking skills which are useful for those questions when you don’t know the exact answer. 

Be familiar with the other names of diseases e.g Kawasaki = Mucocutaneous lymph node syndrome; Buerger disease = Thromboangiitis obliterans. You should also be familiar with the description of the buzzwords. We all know that they will very rarely throw at you an easy buzzword such as “strawberry tongue”, butterfly rash”, “IgA nephropathy” or “tram-track appearance of the GBM”; what you are likely to see, instead, is an erythematous tongue with papillar hyperplasia, rash over the bridge of the nose sparing the nasolabial folds, synpharyngitic glomerulonephropathy, splitting of the glomerular basement membrane, respectively; as you go through AMBOSS, UWorld, and NBMEs, you will start learning these type of description and develop your own pattern recognition.

Was your approach and mindset towards Step 1 different from what it would have been in the exam was still score-based? 

My approach was the same as if the test was score-based since I was cognizant that for Step 2 CK there are not as many resources as there are for Step 1. Therefore, you must have well-rounded knowledge from Step 1 to perform well on Step 2. For that reason, I tried to make sure that I understood the topics well and get the most out of the resources that I selected. 

Furthermore, my recommendation is the same: Try to make sure you master the resources that you selected because it will pay off not just on passing Step 1, but also on Step 2 CK. Even now as I’m preparing for Step 2, the knowledge that I acquired through Step 1 has been of utmost importance in getting questions right on Qbanks, so I strongly recommend that the preparation for Step 1 is as thorough as you can make it. Even with Step 1 being pass/fail, you never know what kind of question you might get on your exam so it’s better to have a good foundation, rather than a poor one.

What Qbanks and self-assessments most closely resembled the questions on your Step 1 exam? 

In terms of question banks, I felt that the ones that approached the difficulty (not exactly to the same question style, but rather in the way that you should think to get the question correct) of the exam were AMBOSS (especially 3-5 hammer questions) and UWorld. I truly think that using both question banks simultaneously during dedicated (in addition to NBMEs) is a great way to not only acquire the stamina of solving questions but also to incorporate and contrast the knowledge that you gain through the explanations. The images that are included in the questions of both these question banks, especially those of histology, boosted my confidence on test day 

Going back, one of the regrets of my preparation was not having completed the full AMBOSS question bank. I completed 1,638 questions out of more than 2,700. 

One of the self-assessments that I felt closely correlated, although not entirely, with my exam experience was the NBME Free 120. This was mostly due to the question style since it was similar in terms of the length of question stems and the way that the questions were formulated. I strongly recommend leaving this one until you’re two to three days off your test day. 

The other NBMEs (25-30) are also useful to assess your weaknesses and tailor your focus. However, they’re not a reflection of the question style of the real exam since the questions on those NBMEs are significantly shorter. Nonetheless, you may still get some vague questions similar to those on the NBMEs, so it’s worthwhile getting familiar with them. In addition, their content is important and you must make sure that you’re familiar with it, especially the images, which are particularly high-yield. 

What resources do you recommend for students studying for Step 1 in the pass/fail environment? 

From my perspective, I believe that it depends on your foundational knowledge. As an international medical student, my curriculum was different from that of American medical schools and the content outline of Step 1, so I had to gather knowledge that aligned with the aforementioned criteria. To do that I used the following:

Review resources 

AMBOSS library: It contains everything you need. Its thoroughness is difficult to find in any other review resource, and it’s organized neatly so it’s easy to go through the articles. The articles on communication, patient-centered care, biases, and insurance were of great help since those sections are not explained as well anywhere else. Articles in the AMBOSS library contain a High-Yield button that condenses the article to the most relevant information. This allows you to focus on the most important information.


In addition, you can assess what you just read with the questions associated with that particular article. All you have to do is click the “Qbank session” button at the top of the article and you can answer questions on the topic.

QBankGif_1 (1)

Boards and Beyond for Step 1: In my opinion, it’s a remarkably thorough review course that goes through the majority of the content that’s tested on Step 1. It was of tremendous help in building my foundational knowledge and understanding the concepts of each subject, especially the neurology section (the brainstem video is extremely helpful). In addition, it includes a question bank that you can use along with the videos, which is quite nice because then you can incorporate active learning as well as benefit from the extra questions. I definitely recommend it, although, keep in mind that going through it all will take time, so make sure to plan accordingly. 

Pathoma: From my point of view, it’s an amazing resource to truly understand pathology. I learned concepts that I initially thought were too difficult to get around. Furthermore, since pathology is one of the subjects most tested on the exam, you need to master the subject to the best of your ability, and Pathoma is an incredible resource to do that. The first three chapters are particularly important so make sure you are comfortable with them. 

Sketchy Micro: If you’re a visual learner, this will work wonders for you. I got so many questions right on micro throughout my preparation due to Sketchy. Even now, when I need to remember those annoying facts about the bugs, I’m able to recall them thanks to Sketchy Micro. It covers almost everything you need to know about micro, however, the rest of it can quickly be reviewed with First Aid (such as basic bacteriology, i.e., transformation, conjugation, transduction, etc; virology i.e phenotyping mixing, reassortment, etc.) 

First Aid for Step 1: I think it's a great book to review things. However, it’s not a great book to learn the material since it’s a bunch of bullet points with no major explanations. With that said, the mnemonics, images, and rapid review section are pretty useful. 


In terms of question banks, I recommend starting them from day one. Start doing them on timed and random as soon as possible. It’ll pay off on exam day. You can start with a free question bank such as Medbullets to familiarize yourself with doing questions; then you can proceed with other question banks, for instance:

AMBOSS Qbank: Excellent learning tool. The questions are challenging (4-5 hammers) and a great way to prepare for the real deal. Since every exam is different, you must be prepared for anything that they can throw at you. The features such as the Attending Tip gives you a different view on how you should analyze the question. It also highlights the facts of the question stem that you should focus on. Moreover, the Qbank has questions on topics that are not covered in other review resources but that are present in the USMLE's content outline. So you must get around those topics through these questions (e.g pilonidal cyst, hidradenitis suppurativa, Kaplan-Meier curve). Furthermore, in February, AMBOSS hosts a free Step 1 Self-Assessment that’s useful to identify weaknesses and tailor your study. 

Pastest: They usually have discounts on their question bank. In addition, it includes two self-assessments. The Qbank helps build your test-taking skills and it has references with First Aid so you can review a topic from a question quickly. 

USMLE-Rx: Questions are straightforward and easy when you compare them with AMBOSS and UWorld. However, the concepts are still important. It also includes two self-assessments. In addition, it has a digital First Aid book that shows you where the question came from, thereby complementing the explanation provided for the particular question. The explanations are ordered by the thought process needed to get the question right i.e., Step 1: identifying the diagnosis; Step 2: associated finding. It’s a helpful feature that shows you the pattern of how you should think about the question to get it right.

UWorld: The breadth of the Qbank and the style of questions are excellent for preparing you for the exam. In addition, the diagrams, images, and tables are spectacular because they gauge the information neatly. Furthermore, you will encounter questions about topics that you will not find in First Aid (e.g electrocution injury). In addition to the Qbank, the two self-assessments are a great way to identify your strengths and weaknesses. Historically, the UWSA2 has been one of the most predictive of your final score, so leave it to the final days of your prep (three to four days off). 

In summary, AMBOSS and UWorld are a must, plus NBMEs (25 to 30, and the free 120). 

What exam day advice would you give to future Step 1-takers? 

Relax the day before the exam—or at least take a half-day off—and enjoy that day by doing your favorite activities whether that is watching movies, exercising, etc. Stick to your normal diet the day before the exam. Try to avoid overly fatty and fast foods to avoid going to bed with a bloated stomach. 

Before you go to sleep, pack the things that you will need for test day, i.e., exam permit, ID (passport), soft earplugs, and snacks. I recommend bottles of water, some nuts, and protein bars; that worked well for me and I did not feel hungry throughout the exam (as a matter of fact I didn’t even finish all of them). Some people like to bring coffee or caffeinated beverages. You can bring them but beware of the effects of excess caffeine on the renal system (it’ll make to go to the restrooms repeatedly!). 

Try to avoid big lunches because that will cause a “sugar crash” and you’ll feel tired and sleepy after that lunch; however, if you stick to those items that I mentioned, you will be fine and not feel hungry. The night before, try to go to bed early to get your eight hours of sleep. I know it’s difficult to do that so it may help to do exercise or some type of physical activity during the day to feel tired at your bedtime. 

On the morning of the exam wake up early (at about 6 a.m) to take a shower. Wear comfortable clothes (e.g., sweatpants with the least amount of pockets as possible, a comfy shirt, and sneakers; do not wear accessories such as watches and bracelets). Take a light breakfast: I had a half-cup of coffee, some oatmeal, and toast with eggs. As you may be aware, you need to get to the test center at least 30 minutes before your scheduled time, and you never know how traffic will be, so plan to arrive early. If you can, visit the center a few days before and assess how long will it take to get there.

During the test, skip the tutorial (you can do it while you’re doing the Free 120). However, make sure you do the part that assesses if the headphones are working. The rest of the time of the tutorial will get added to your break time (and you’ll have around 60 minutes of break). In terms of the breaks, I took one every time I finished a block. I started with five minute breaks during the first two blocks, then increased to 10 with the following two, then to 15 minutes. You can familiarize yourself with how to take breaks with the NBME Free 120 which has the same software as the real test (option to take breaks, timer with time for the current, and whole day exam day). 

While taking breaks, be aware that every time you go out of your test station, they will examine your pockets, hands, forearms, and socks (they’ll tell you to lift your pants a bit). When you return, they’ll repeat the process, so some of the time of your break will be spent on those procedures, hence the advice to wear pants with the least amount of pockets. 

As I said before, I recommend bringing your soft earplugs because if your test environment is noisy, you may also, concomitantly, use the headphones that are hanging in your test station to keep the focus on your test and not be distracted by your surroundings (e.g., other test-takers that are typing on the keyboard, nearby construction, or traffic). 

You may also find this video from Dirty Medicine helpful:  “Top Biohacks to score 260+ on USMLE”, as it contains pretty useful tips. 

Do you have any other advice that you would like to give to students preparing for Step 1 as a pass/fail exam? 

The key is doing as many questions as you can and spending time reviewing all the answers (correct and incorrect). Even though it will take more time to review the blocks thoroughly, it’s important to spend that time since it allows you to identify what went wrong if you got the question wrong. When you get a question wrong try to reflect on the reason why, i.e., missed a detail, went through it too fast, didn’t know the factoid, confused by some lab finding, careless mistake, etc. In that way, you can assess where the problem is and get insights into your test-taking skills and where you should focus your attention. 

I recommend doing at least two blocks of questions per day, and then you can increase the number of questions. In addition, when you take an NBME (four blocks of 50 questions) you can take three additional blocks of questions from AMBOSS to simulate exam day. It’s worthwhile doing that as you’ll familiarize yourself with the feeling of doing questions for seven hours. Avoid focusing excessively on the percentages you get correct, it doesn’t help at all. Instead, you should concentrate on learning the content and why you made certain mistakes. You should also focus on your corrects, especially if you got it correct by chance. 

Do not burn out during your preparation. Take it day by day and take care of your mental health. If you feel overwhelmed, taking a walk outside or meditating daily for five to 10 minutes will make you feel better. Maintain contact with your close ones. If you need to take some days off, take them. Trust your knowledge and yourself. That’s one of the most important things—believe in yourself and you’re halfway there. At the end of the day, enjoy the journey instead of the destination. Do not let the exam discourage you. As former president FDR said, “The only thing we have to fear is fear itself”.


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Paulino Garate

Paulino Gárate is a fourth-year medical student based in Chile. Before entering med school, he completed a cancer cell biology course at the University of Chile where he developed a keenness for the field of medicine and oncology. He has an interest in patient-centered care and its outcomes in health care. After graduating, Paulino hopes to pursue research positions within the US. While in his free time, he enjoys spending time with his four-legged friend, paddle boarding, and cooking a myriad of different styles of cuisines and salads.