USMLE Step 1 Exam Facts
When should I take Step 1?
Most medical students take the USMLE Step 1 test after finishing their basic science
classes and before starting the clinical clerkships, usually in the summer between
the second and third years at most programs. Many institutions offer a 1-2 month
break during this time for students to study and take the test, with some students
deciding to take it earlier and have a longer break whereas others use as much time
as possible for studying. This decision may have a large impact, given the heavy
emphasis placed on the test results by program directors.
A 2002 study looked at student scores based on the timing of when they took the
USMLE Step 1. Students who took the exam earlier tended to have a better academic
record based on preclinical grades and MCAT scores. Many students who took the exam
later did so because of personal issues or a need for remediation after second year
classes. As might be expected, the pass rate among students who took the exam earlier
was higher than it was among those who took it later, but this is confounded by
the difference in academic record between these two groups. When performance was
adjusted based on these variables there was no significant difference in scores
related to when the exam was taken.
One can approach this data in several ways. Decreased retention of material with
longer delays after finishing the basic science classes is unlikely to be much of
a factor as there is a relatively short interval between when most students finish
basic science classes and take the exam anyway. This is in contrast to Step 2 where
there is often a longer interval between when students finish clinical clerkships
and take the exam, a factor which has been correlated with performance on the test
(see "When should I take Step
2?"). In addition, students who fear they will do poorly on the test and
take extra time to study may not do any better on the test than if they had taken
Pohl CA, Robeson MR,
Hojat M, Veloski JJ. Sooner or later? USMLE Step 1 Performance and Test Administration
Date at the End of Second Year. Academic Medicine 77(10), October Supplement 2002,
How much basic science material from USMLE Step 1 will I end up remembering in the
The retention and relevance of basic science material learned during medical school
has long been a concern. This is part of the reason there has been a shift in medical
education towards including more clinically relevant material during the first two
years of medical school. There has also been a shift towards more patient cases
being included in USMLE Step 1; previously only 30% of cases used a patient-based
format, whereas now roughly 70% of cases do.
A 2008 study examined the results of including unscored Step 1 questions on the
Step 2 CK exam. Students answering the questions as a component of the Step 2 CK
exam, i.e. later in their medical training, performed approximately 6-7% poorer
than students answering the questions as a component of the Step 1 exam. This decline
was greater for questions that were presented in a style other than a patient vignette.
The question category with the largest drop in performance was biochemistry, followed
by microbiology and pharmacology. The drops were less dramatic for physiology, anatomy,
and pathology. Performance actually increased for human behavior related questions.
Changes in performance likely reflect emphasis placed during clinical clerkships,
where biochemical principles are rarely discussed but aspects of human behavior
such as communication and mental disorders are frequently discussed.
Similar studies have been conducted over the past three decades. Interestingly,
the results of the most recent study were similar to those of earlier studies despite
the changes made to medical education. In fact, the magnitude of decline was actually
worse on the more recent study than those from years prior to changes in medical
school curricula. Some of this may be secondary to fourth year medical students
taking Step 2 later in the year, therefore increasing the interval since Step 1
and decreasing retention of the material.
Ling Y, Swanson DB,
Holtzman K, Bucak SD. Retention of Basic Science Information by Senior Medical Students.
Academic Medicine, Vol. 83, No. 10 / October 2008 Supplement, 582-585.
How much is my performance on the USMLE exams affected by the medical school I attend?
A variety of factors go into a student's choice of medical school. Schools vary
in geographic location, curriculum, teaching quality, and reputation. It is difficult
to compare medical schools in overall quality, except in the form of published rankings,
which are of questionable validity. It is also unclear if differences between medical
schools significantly impact a student's eventual performance in clinical situations
or on standardized tests.
A 2008 study compared USMLE scores across multiple medical schools. Overall USMLE
scores did vary among institutions, as would be expected. However, the majority
of these differences could be accounted for by differences in incoming students,
particularly MCAT scores. In other words, schools admitting students who are better
test-takers tended to have higher average USMLE scores. Approximately 85% of the
variation between schools can be traced to this variation among incoming students.
Only about 15% of the variation in USMLE score across different medical schools
could be traced to factors related to the school itself. Little of this difference
could be traced to differences in curriculum or school level-educational policies.
Private school students tended to perform better on Step 1 but worse on Step 3.
The geographic location of the school also impacted scores. This study did not directly
address the quality of teaching that students receive, in part because this is difficult
to assess and quantify. Overall these findings suggest that the majority of variation
in USMLE performance among different schools is likely secondary to traits that
the students bring into the medical school environment, rather than differences
between medical schools themselves.
Hecker K, Violato
C. How Much Do Differences in Medical Schools Affect Student Performance? A Longitudinal
Study Employing Hierarchical Linear Modeling. Teaching and Learning in Medicine
20(2), 2008, 104-113.
Are my MCAT scores predictive of my USMLE and medical school performance?
Much as the USMLE Step 1 score is an important variable in the residency application
process, the MCAT score is given important weight in the medical school application
process. Medical school admissions officers are faced with the daunting task of
determining which students are the most qualified, comparing applicants from different
institutions of different quality and grading schemes. The MCAT is meant as an objective
and consistent means of comparison, though other factors are certainly considered
in the medical school application process.
A 2007 meta-analysis evaluated the relationship between the MCAT and medical school
performance. There was a small to moderate correlation of MCAT performance with
performance during the preclinical years, with the r value equal to roughly 0.39.
There was also a correlation of certain subtests with preclinical performance, particularly
the biological sciences subtest. The correlation was less strong between MCAT performance
and performance during the clinical years. The writing subtest of the MCAT was shown
to have no correlation with either performance during the preclinical years or the
A small to moderate correlation was also found between MCAT and USMLE scores, with
r values ranging from 0.38 to 0.60. This correlation was highest for USMLE Step
1. Among the different MCAT subsets, the highest correlation was found for the biological
sciences and verbal sections. There was near zero correlation between the writing
subtest and USMLE scores.
Donnon T, Paolucci
EO, Violato C. The Predictive Validity of the MCAT for Medical School Performance
and Medical Board Licensing Examinations: A Meta-Analysis of the Published Research.
Academic Medicine 82(1), January 2007, 100-106.
Are my USMLE scores affected by whether my medical school has a problem-based or
traditional curriculum during the basic science years?
Over the past several decades, many medical schools have changed their curriculum
from a more traditional format to problem-based learning (PBL). Studies have shown
that graduates of PBL curriculums tend to have better clinical performance during
residency, though not to a statistically significant degree. Students also generally
prefer the PBL curriculum when given the choice. However, some worry the PBL approach
may compromise basic science education, potentially hindering performance on USMLE
exams, particularly Step 1.
Multiple studies have examined this concern and the results have been mixed. The
majority of these studies have demonstrated no significant difference in test performance
between students on the two tracks. Exceptions include one study of students at
the University of New Mexico which demonstrated a statistically significant increase
in Step 1 scores among students taking a traditional curriculum and a trend towards
improved Step 2 performance in students taught with a PBL curriculum. A study of
University of Missouri students demonstrated improved performance on Steps 1 and
II with a PBL curriculum. Students at Wake Forest University and Michigan State
University showed similar test performance regardless of teaching style. While these
studies do not draw any hard and fast conclusions, they suggest that the two tracks
are roughly equivalent in terms of how they prepare students for the USMLE. A potential
confounder in these studies is that students with less basic science background
entering medical school may favor programs offering a PBL-style curriculum, as decreased
basic science background is an independent predictor of poorer USMLE performance.
Enarson C, Cariaga-Lo
L. Influence of Curriculum Type on Student Performance in the United States Medical
Licensing Examination Step 1and Step 2 exams: Problem-based Learning vs. Lecture-based
Curriculum. Medical Education 35, 2001,1050-1055.