All the Basics About the USMLE Step 1

Facing the United States Medical Licensing Examination (USMLE) is no one’s idea of a fun day — and Step 1 is arguably the most daunting portion of this three-part exam.

Understanding what’s in front of you is the best way to get prepared and allay any concerns you may be experiencing.

Follow this link for a complete overview of the USMLE and its different components.

Overview

Step 1 of the United States Medical Licensing Examination (USMLE), often referred to colloquially as “The Boards,” is the first test in a three-step exam series that is required for anyone wanting to practice medicine in the United States. It is designed to test basic science knowledge and its application to medical practice. Step 1 has the reputation of being the most challenging exam in the series. It covers a great breadth of topics and requires significant time devoted to rote memorization.

Eligibility

Medical students are eligible to take Step 1 if they are officially enrolled in or graduates of:

Registering

Current U.S. or Canadian MD or DO students as well as medical school graduates can register for the test on the National Board of Medical Examiners (NBME) website, while non-U.S. medical school students or graduates must register via the ECFMG website.

As of 2015, the cost to take Step 1 is $590.

Scheduling

When you register for Step 1, you must first select a three-month block in which to take the exam. Once your registration is processed by NBME/ECFMG (which can take up to four weeks), you’ll receive a scheduling permit with instructions on how to make an appointment at a Prometric test center.

There are numerous U.S. and international locations, with scheduling permitted up to six months in advance. Choosing your test date is done on a first-come, first-served basis, so it’s important to respond as soon as you receive the scheduling permit. Peak seasons for the USMLE are May through July and November through December. Please note that test centers are closed on local holidays, and there are no tests offered during the first 14 days of January.

Determining Which Year to Take USMLE Step 1

Because Step 1 tests your ability to apply basic science concepts to medical practice, most medical students plan to take the exam after completing their basic science years. Until very recently, the majority of U.S. medical school curricula covered the basic sciences during the first two years of programs, after which students would begin clinical rotations in hospitals to complete their final two years of preparation. Today, however, many medical schools are moving clinical experience earlier in their programs and having students take basic science courses at the same time as they receive this clinical experience.

Students may, for example, learn cardiac biochemistry, physiology, and pathophysiology while simultaneously doing a rotation in a hospital’s cardiac unit. This curricular shift has led students to take Step 1 as early as at the end of their first year or as late as following their third year, depending on each particular school’s structure. That said, any medical student who wants to practice medicine in the U.S. must take the test prior to applying for residency positions (a process that typically happens in September of the final year of medical school).

Structure

Step 1 is a computer-based, one-day exam that lasts about eight hours. In May 2015, the number of multiple-choice questions decreased from 322 to 308. These 308 questions are divided into seven blocks of 44 each, with 60 minutes allocated per block. It’s important to realize that you cannot return to review your answers once you finish a block.

You will get one 45-minute break, which you can increase slightly by skipping the optional 15-minute tutorial or by finishing a block early.

Content

Step 1 tests your ability to apply basic science knowledge, as described on the USMLE website:

Step 1 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. Step 1 ensures mastery of not only the sciences that provide a foundation for the safe and competent practice of medicine in the present, but also the scientific principles required for maintenance of competence through lifelong learning.

The Boards have long been notorious for testing detailed basic science topics that have no direct clinical application, such as the Krebs Cycle. In response to criticism for including this type of content, the test writers have dramatically increased the percentage of clinically-based questions in recent years.

Most questions require interpretation of graphic material, identification of pathologic and normal specimens at both the gross and histologic levels, and problem-solving through the application of basic science knowledge.

The USMLE Step 1 Content Description and General Information guide lists the following content areas as ones that are assessed:

  • Anatomy
  • Behavioral sciences
  • Biochemistry
  • Biostatistics and epidemiology
  • Microbiology
  • Pathology
  • Pharmacology
  • Physiology
  • Genetics
  • Aging
  • Immunology
  • Nutrition
  • Molecular and cell biology

These general topics are broken into system and process categories and are accorded the following importance within each category:

System

15–20%:

  • General Principles of Foundational Science

60%–70%:

  • Immune System
  • Blood & Lymphoreticular System
  • Behavioral Health
  • Nervous System & Special Senses
  • Skin & Subcutaneous Tissue
  • Musculoskeletal System
  • Cardiovascular System
  • Respiratory System
  • Gastrointestinal System
  • Renal & Urinary System
  • Pregnancy, Childbirth, & the Puerperium
  • Female Reproductive & Breast
  • Male Reproductive
  • Endocrine System

15%–20%:

  • Multisystem Processes & Disorders
  • Biostatistics & Epidemiology/Population Health Social Sciences

Process

10%–15%:

  • Normal Processes

55%–60%:

  • Abnormal Processes

15%–20%:

  • Principles of Therapeutics

10%–15%:

  • Other (This content changes from exam to exam.)

Scoring

The score range for USMLE Step 1 runs from 1–300, with the national average falling between 220 and 240 and a standard deviation of about 20. While USMLE lists the minimum passing score for 2015 as 192, most residency programs in the U.S. require a score of about 220 or above. And for competitive specialties, candidates’ scores need to be well above 240.

The Step 1 score report includes the following information:

  • For the Tester:

    • Whether you passed or failed
    • What your three-digit score is
    • A graphical representation of your performance for each testing category
  • For the Test:

    • What a passing score is
    • What the mean score is
    • What the standard deviation is

Scores are usually available three to four weeks after the exam, but USMLE recommends allowing eight weeks in case there are irregularities with the test.

The Boards (as you may now refer to them) are indeed challenging, but with planning and preparation, you’ll be in a strong position to pass this first hurdle on the difficult — and rewarding — path to becoming a doctor.

Follow this link for more guidance about preparing for the USMLE and medical careers advice.