How to Prepare for the USMLE® Step 1

Sophie Moran - Mar 24, 2020

Update: The USMLE®  Step 1 exam switches to a Pass/Fail exam as of January 26, 2022. This means you are no longer dependent on the previous three-digit score. You can learn more about how to study for the new Step 1 exam from Dr. Ryan Colaço here. Read the official USMLE announcement here.

There is no doubt that to score well on the USMLE® Step 1 exam you have to know the material inside out. Thankfully, developing a familiarity with the most effective study tips, developing test-taking strategies, and gaining exam insights will also help you prepare for the exam and will assist you in achieving your highest score.

AMBOSS Chief Editor and Physician, Zebulon Tolman, is here to help you do just that. From understanding the question structure and format to time management, Zeb provides deep insight into the Step 1 exam. With extensive knowledge from both student and question writer perspectives, his Dissecting USMLE® Step 1 webinar will give you invaluable advice for your Step 1 preparation.


Here are 5 key takeaways from the talk:

The Step 1 Exam 

Firstly, what is it? 

Step 1 is an eight-hour, computer-based examination that is comprised of seven blocks. Each block is 60 minutes and has up to 40 randomized single-best answer questions, making a total of 280 multiple-choice questions (MCQs). Depending on length and difficulty, you should allow yourself about 90 seconds per question. 

The key to succeeding in Step 1 is knowing what the test writers expect of you. And what they really expect of you is to apply foundational science concepts, which comprise approximately 50% of the questions. Other questions will go into diagnoses and patient management and a minority of questions will deal with communication and practice-based learning. 

Use your knowledge of the different disciplines to your advantage. For example, pathology will feature in 45-52% of questions and genetics will appear in 5-9%, so you should spend more timing studying pathology than genetics, etc. 

The Exam Questions

One of the best ways to score high on the Step 1 exam is to understand how the questions are made.The first thing to know is that the NBME® exams, the body that writes them, emphasize understanding and application of knowledge. Using fact recall alone is not sufficient. You must have a good understanding of what it is you are studying. 

It is also important to know that items will reflect real-life tasks. This is seen in the clinical vignettes. In real life, patients come in with symptoms, you do a work-up, and eventually, arrive at some therapeutic option. Step 1 question stems reflect this basic process, despite including a mix of important and unimportant information.

Another feature of Step 1 is the presence of first-order and second-order questions. First-order questions are straightforward, such as “what’s the diagnosis?” Second-order questions may have an intermediary step, such as finding out the underlying pathology before applying this information in an additional step. Second-order questions require you to figure out what the diagnosis is and then answer the question. 

Step 1 questions can include medical imaging or illustrations, graphs or charts, clinical examination videos, interactive media, and communication and ethics videos. 90% of the questions will feature a clinical vignette. The clinical vignettes follow the same structure:

  1. Presentation
  2. History 
  3. Physical
  4. Diagnostic findings 
  5. Follow-up info
  6. Lead in, i.e., ‘which of the following’ and ‘most likely’

How to Prepare for USMLE® Step 1 

The best way to prepare yourself for Step 1 questions is to do Step 1 questions. Studies have shown that the more unique questions you do, the higher you will score. So do more questions! You should also start studying as early as possible. With few exceptions, it’s best to start completing questions earlier rather than later. It’s when you get questions wrong that you learn the most. 

Next, focus on the content review that is high-yield. This means not only content that is most likely to be featured on the exam, but also your own personal weak points. Once you patch up your understanding of a specific weak point, return to questions once again to solidify your understanding. 

Strategies for Answering Questions  

The bad news first: there are no tricks. To score well in your Step 1 exam you have to practice, practice, practice. With that said, there are some guiding strategies that can help. For example, there are no negative points for answering a question wrong, so never leave a question blank. And remember, the NBME® is not trying to trick you. Questions can be answered with medical knowledge and reasoning skills alone.  

Another strategy is time management. Being efficient is crucial to scoring well. Here are some tips on time management:

  1. Answer the moment you have enough info.
  2. Read the question before reading the information that precedes it.
  3. Do not read all lab values by default. 
  4. Highlight sparingly. 
  5. Remember that all questions are worth 1 point. 
  6. Do not expect to have an epiphany - if you are unsure of something, move on.
  7. If unsure, select the option that is more related and/or familiar. 

Test Day 

The first thing you need to tell yourself when it comes to the day itself is that nobody is perfect. So don’t worry about getting questions wrong - everybody does. You will see things you have never seen before, but this is okay. It is impossible to prepare for everything and the NBME® will add some new topics into the mix. Everyone is in the same boat here. 

Finally, on test day, it is important to take care of yourself. Don’t forget to eat and sleep, and don’t do last-minute studying. Trust your training and have confidence in yourself and your knowledge.