by / Friday, 27 January 2012 / Published in USMLE Advice

“Step 1 Is The MOST IMPORTANT Test You Will Ever Write In Your Life”


There’s no secret to the fact that the USMLE Step 1 exam is the toughest, and unfortunately most important test you will write throughout the entirety of your medical career.  This test takes everything you’re supposed to learn in your first twenty months of medical school and crams it all into a seven hour window – and this seven hours can make or break your career.  It did for me; I grew up dreaming of being a plastic surgeon but alas, a 250+ was not in the cards for me.  That’s okay though, I’ll keep trying.  The Step 1 is weird because it really has no direct indication of how well someone will be with patients, how strong of a diagnostician they’ll become – it simply tests one’s ability to take a challenging test.

Because of this it’s important that when you approach this exam, you do so with the knowledge that it’s simply a way to get your foot in the door and get yourself residency interviews – becoming a fantastic physician after that will be completely up to you and how hard you’re willing to work to become great.

Step 1 gets your foot in the door

Honestly, that’s really what it’s main purpose is… Want to get into Surgery?  Get a certain score or you’ll fail to get even interviews.  Want to get into Dermatology?  Get a high score or it doesn’t matter how much research you’ve got or how many publications you’ve been a part of, you won’t get interviews.

Why do they use Step 1?  It’s simply the method the powers-that-be have chose to compare each and every one of us.  Is it fair?  Probably not, but those are the rules and we all have to abide by them.

And here’s just a harsh truth that happens as a result of this:

  • Many poor students with good step 1 get residency
  • Many strong students with poor step 1 don’t get residency
It’s an extremely sad and unfortunate fact, but those are the facts.  A poor Step 1 score will put you at an instant disadvantage and will force you to be fighting for your career the rest of the way.  Residency program will question whether you have what it takes to deal with patients – even though your clinical preceptors write good LOR’s.  Residency programs will question whether you’ll be able to pass the Step 3 and the subsequent required licensing exams – even if you’ve got a rock-solid scholastic record and have passed all other required exams.  You see, the fact is that this test is make-or-break for many students, especially those who are Foreign Medical Graduates (FMGs) or International Medical Graduates (IMGs).
The one factor that can completely erase a failure on the Step 1 is coming back and blowing it out of the water.  This tends to make program directors assume you had an ‘off day’ and that your new/high score is the real you.
Now I don’t tell you this to scare you, in fact, I tell you to motivate you to do well.
There’s a fairly long list of reasons why some students do poorly on their Step 1 exam, but below I’ve outlined the most common links I’ve been able to connect between strategy and results.


The main reasons why so many students do poorly:


Lack of taking it as seriously as it is

It’s hard to believe that with all the talk of competitiveness some students still dismiss the difficulty of this exam, but this is one of the major causes of failure.  Students who simply aren’t studying their hearts out and instead treating it like a high-school quiz.  This test should be approached with extreme caution and your goals should always be high.  Shooting to simply pass is in my experience a recipe for disaster as students tend to only study hard enough to put them near the passing range.  Instead, students who are aiming high tend to pass rather easily because their goals are so ambitious that even if not met, they’re still well above the passing line.


Following what everybody else is doing regardless of what you know works for you

I remember on my first day of medical school all the senior students were giving us newcomers advice already about how to get ready for the Step 1 exam – what books to use, how much to study, etc, etc.  The problem with following everybody else’s advice is that everybody learns and masters material differently.  If you love learning by listening, but your advisors (senior students) are telling you to bury your head in any number of the study guides out there, you might run into some problems.

Now, you should realize there are a couple main things you absolutely must have in your Step 1 preparation arsenal:  A good question bank and a good review book.  What you do with these sources should be tailored directly to your specific form of learning, not your classmate’s suggested strategy.


Failing to ‘practice’ as you would for a big game

It always frustrates me when a student comes to me saying they failed the Step 1 exam, and then when I ask how they did their questions they say in un-timed mode.  This exam is brutal and in order to build your stamina you absolutely have to do questions as  you’ll experience them on the Step 1, in full 46 question blocks in timed mode.  There’s no excuse for this one – just do it!


Studying passively instead of proactively (this is a game changer)

One of the biggest reasons why people fail is simply because their preparation process was nothing more than reading through a review book.  Sitting there and reading the material is what we call “passive learning”, and when you aren’t actively engaged in your learning process then you run the risk of retaining very little of the information you’re studying.


Using question banks the wrong way

This is something that you really can’t blame yourself for, simply because nobody is really actively teaching you how to use the question banks for maximizing your results.  I’d love to see medical schools holding a class on question bank use, simply because the way you use a question bank can be the difference between a failure and a pass, or a 215 and a 240.  So you really need to know how to use the qbank for the best results – and just doing the questions is not usually enough to get the job done.

* I’m going to explain how to use a question bank properly in a little bit.


Not using question banks at all

This is probably the biggest mistake you can make while preparing for the exam.  It’s been proven over and over again that a solid run at a question bank is a necessity for success.


Using only the recommended ‘study guides’ before truly learning the material in-depth

Everyone recommends using this guide or that guide, but they fail to mention that you can’t use a study guide to learn, nor is that the purpose of the study guide.  These ‘high yield’ study guides are designed to bring to your attention the topics that are most likely to be asked on the exam, they are not meant to go into the depth that you’re required to know for success.

It always drives me nuts when I hear that study guide X or study guide Y was no good, when in fact the people making these comments are only saying this because they fail to realize that a study guide is exactly that – a “guide”.  It is designed to guide your studying, so you have to be able to recognize the topic and dive two, three, or four levels deeper than the guides are going.

When you understand this concept, it makes a lot of sense why you can’t only use a study guide – unless of course you know your material well and need only guidance.


Not setting a date to write

When you don’t set a date for your exam, you fail to create that sense of urgency that you really need to light the fire under your butt.  Figure out how much time you realistically need to prepare, then set the date in stone and DO NOT change it.  You set the date as a deadline, there’s no sense in setting a date if you have no problem changing it at will.  Of course, you have to be sure you’re going to pass and we’ll discuss how to ensure this a little later.


Treating study as a part-time job (when it should be a full-time job)

Some students take their study notes here and there with them, assuming they’ll grab a few minutes of study here and study there, but this isn’t what we call a “serious student”.  Treating your preparation as if it’s not the top priority is a dangerous game and if you’re serious about success on this thing, you better carve out time each and every day to cover the material.


Studying for more than 3 months

If you’re following the advice in the last point and treating your studying as a full-time job, then there is absolutely no reason why you need more than 3 months to prepare – even if you’re a foreign grad.  I personally got through the Step 3 question bank in 12 days when I studied full time (9am – 4pm), and after getting through a question bank you’ve been exposed to all the material you’ll see on your exam, so sit down and master it from there… There’s no need to go beyond 3 months if you’re taking your preparation seriously.


What you can and should do to become successful:


Treat this exam as if your life depends on it, because your career definitely does

I once spoke to a friend who said ‘treat this exam as if your life depends on it’, because your career definitely does.  And it’s becoming more and more true as each match year progresses.  So many students are left unmatched after each match season and the commonality between these students is a poor score on the Step 1 exam.

Treat this thing as if it was a fragile egg!  It is extremely important that you take it seriously and work as hard and smart as you possibly can.


Know how you learn and apply it to the step 1 exam

Remember, advice from others should be welcomed, even encouraged, but if what works for them doesn’t fit into the way you learn, don’t be crazy and test a new form of studying for the exam.  Use the sources they recommend, these sources are known to be the best for success, but use your own study strategies that helped you get through your first two years of medical school.


Think of each USMLE exam as a super bowl, you can’t expect to win if you don’t practice hard

You’ve likely heard the saying “Practice makes perfect”, but I have an even better saying – “Perfect practice makes perfect”.  This means that you can do 25000 questions if you want, but if you aren’t doing them in the same type of atmosphere and with the same urgency as you’ll experience in the real exam, then you’re risking your score.

What does this mean?  It means you should be doing questions in blocks of 46 at a time (or whatever number they’re using for each block these days), and in the ‘timed mode’.  This means you’re practicing questions and also doing so with the same pressure you’re experiencing on the real exam.

The worst thing would be to get to the real exam without having built up your stamina and thus suffering simply because you were too tired to continue.


How to study actively using the qbank 

Remember earlier how I wrote about studying actively instead of passively, well that means actively doing questions and then actively searching for deeper information about where you’re weak.  So you do a block of 46 questions and you go back and see that you aren’t 100% confident with the concept in questions 3, 6, 33, and 41.  Take action and open up a textbook and take notes on these areas where you’re weak… this is the type of proactivity that leads to solid USMLE scores.


The right way to use a question bank to get the most out of it while not draining yourself

One of the biggest mistakes I see many students making, and I used to be guilty of this too, is to focus on quantity of questions done instead of the quality with which they’re done.  What this means is that the goal isn’t to simply do as many as possible, rarely does this truly lead to learning, mastering, and most importantly retaining the information you need to be successful.  The goal instead should be to use the question banks as a tool for exposing yourself to the information you’re going to be tested on, then taking this information and learning it as well as you possibly can.

But how do you do this?  The answer is simple… Choose ONE question bank and do it thoroughly.  But there’s a bit of a different approach I’ve been taught and that I’ve also taught my students, and although it may be a bit off-beat, it works extremely well.

Here’s the strategy:

  • Do questions in a timed block of 46 (doing them all in a row will ensure you don’t falsely elevate your score by getting hints about information in upcoming questions)
  • After the block is complete, go back and look at the questions one at a time (if you got it right, make sure you know the information and didn’t simply guess… if you got it wrong, dive in and take notes and explore more in-depth textbooks to get a good grasp on the information)
  • Write all question material in a separate blank notebook, which will give you a goldmine of information to study from once you’ve gotten through the entire question bank.
While this seems to be a long, drawn-out way of learning, isn’t the goal to actually learn and master the material?  If your goal is to succeed on the exam, this will ensure you truly know your stuff!


How to use a study guide the right way to ensure success 

Note the word “GUIDE”… a study guide is an undeniably amazing tool for your Step 1 (or 2 or 3) preparation, but it is NOT designed to be the only thing you use to learn the material.  It is a blueprint for helping you know the high-yield material, and only once you’ve adequately learned all of the medical material will a study guide truly have a place in your preparation.

You can also use a study guide to let you know what’s high-yield, but they aren’t going to dive deep into the information about each topic they list, that’s your job as a medical student to explore and master.

Don’t make this big mistake of only using a study guide to study… Use a question bank, use your textbooks to fill in the gaps, then once you’ve mastered the material use a study guide to give yourself the review you need for success… Open up a study guide and point to a topic they mention, then if you can talk in depth about each topic you know you’re probably ready to succeed on the exam.


Setting a date and crafting out a study plan and how to ensure you stick to it

Earlier I mentioned how not setting a date was a common reason for failure because the longer you wait the more you forget.  Here my only suggestion is to go and book a date NOW, then work your butt off so that you’re ready by then.  No excuses on this one, it s imperative to give yourself a deadline for your goals – and anything longer than three months indicates you aren’t studying hard enough or giving yourself enough time everyday to get ready.


How to treat your studying like a job/business

Real success requires a real commitment.  This means carving out blocks of time every single day where you will study, and there’s no excuse for not sticking to it except being sick.  Treat your USMLE prep like it’s your job and your results will demonstrate the effort, treat it like a part-time hobby and your results will also reveal this attitude as well.


What’s the optimal study period and how do i know if i’ll be ready for sure

This is more of an individual thing, but let’s use my personal background to give you an idea of what it takes.  I graduated from an off-shore school which is considered one of the top off-shore school, and I believe the education I received was excellent.  So coming out of the first two years I didn’t feel lost.  My preparation for the Step 1 at the beginning wasn’t as wise as it should have been, mainly because I wasn’t given a blueprint like I’m giving you here.  So three months is what I took, and that involved having a preparatory course in the middle.

Once I knew how to prepare for the USMLE’s however, I can say that one month of hardcore, full-time preparation is adequate to give you the results you want.  For example, when I studied for the Step 3 I set my date on August 1st for September 1st – meaning I had exactly one month to prepare from scratch.  I did 8-5pm daily, questions all morning taking notes, hardcore review sessions in the afternoon (actually recording my notes into my iPod as well), then off to the gym at 5pm where I’d workout and run to the sound of my own voice talking out the notes I’d taken from my question bank information.

It’s intense, but I know as a medical student you’re probably not working a job, so something as intense as this is completely doable and it works!


The last critical step you must take in order to guarantee yourself that you will in fact pass the exam

If you follow this step it’s all but guaranteed that you’ll pass, and that step is to take an NBME exam.  These are exams that are put out my the NBME and the questions are actual questions that they’re currently using on the real USMLE exams.  These exams are essentially testing you on the exact type of questions (and maybe even some you’ll see again) that are currently being used, so it will very accurately tell you whether or not you’re ready to write the real exam.

Take the results of this very seriously, because they’re usually within 5-10 points of what you’ll get on the real USMLE.  Now the key is to realize that there may in fact be a drop in score on the real exam, so if you want to “just pass”, you still want to aim for at least a 200 on the NBME, giving you that cushion just in case.  Also, if you’re looking for a super high score then you can gauge based on your results whether it’s likely you’ll achieve it.

If you’ve achieved your desired level then fantastic!  You should still take a look at the feedback to see if you are weak in any particular area, then give yourself a week or so to get stronger in that area and bring your real score up even more.

If you haven’t achieved your desired level, well that’s exactly why the NBME is so effective… See where your weakness are and work super hard to bring them up.  Take a few days per weakness and really try to strengthen them, and then retake an NBME to see if you’re at a higher level.  Once you’ve achieved your desired level of success on the NBME, you’re ready to write and you are most likely going to fall somewhere very close to that score.


I truly hope you’ve gotten a lot out of this, I know back when I was getting ready for the Step 1 I could have used something as detailed as this.

Let me know if you have anything to add to this that can help other students by leaving your feedback in the comments section below.

Best of luck!


  1. Iminder says : Reply

    Just came across this while searching for nbme score
    Correlations! I wish I had read this before starting my prep!! I
    Went to med school overseas and I feel like I have spent way too much time studyin for this exam. Now with my exam ten days away I feel exhausted and tired. Hopefully this is normal for everyone and I’m
    Not the exception.!! My
    Nbmes score have been consistent 214,219,228 ( the last one I took a few days ago). Do u have any suggestions on how to make it through the last push ?? I have ten days and a lot
    To do but I feel Brain fried!!

  2. Paul Ciurysek, MD says : Reply

    Hi Iminder,

    The good thing is that you are close to your exam date and your scores are consistently well over a passing score. My main recommendations at this point will be to: 1. Rest well (you need a fresh mind in order to do as good as you possibly can), and 2. Focus on weaknesses (draw from the NBME feedback which areas are your weakest, and focus on bringing those up in the coming days).

    Aside from that, keep reviewing everything to keep it fresh, and I bet you will do just fine.

    Best of luck on your exam!

  3. John P says : Reply

    Hey guys, I am really worried. okay here it goes, I went to a medical school overseas, they taught decent, but I got sick and didn’t study for 2 semesters now. So basically, for the past 8 months, I haven’t studied much. I am scheduled to take USMLE 7 months from now. I took a practice NBME a couple days ago, and guess what I scored a 40 on the CBSSA score reporting which is a score that is not even close to the passing score of 300. 300 is the passing score, 700 is a 250 equivalent, and I scored a 30 lmao. But now I am starting to read first aid and do uworld. Do u think if I do first aid and uworld I can increase my score to a 600 in 7 months? Please help. I am literally freaking out, I scored so bad and 7 months to go.

    • John P says : Reply

      So basically I got 80 questions correct out of 200 on NBME. This is real bad. Is it possible to increase NBME score to 600 in 7 months with just first aid and uworld and goljan. I am gonna read first aid, uworld and goljan as well. I can’t afford to take a review course because I have a budget problem.

    • Paul Ciurysek, MD says : Reply

      Hi John,

      I would highly recommend that you use more than FA and UW since you have quite a ways to go in order to boost your score. Scoring this low tells me that you have a lack of basic science knowledge and that you need to build that back up from the ground-up. I would suggest doing one of the following: 1. Either go through all of your basic science notes and books again, re-do your notes from scratch and basically re-start from the beginning OR 2. Use the fully comprehensive Kaplan series that covers everything in great detail.

      The reason why I recommend those options is because if you use FA and/or UW, it is assumed that your very basic knowledge is fairly solid, but the scores indicate a fundamental lack of those basic science skills. Once you’ve gone through everything from the beginning and have that strong foundation, then a review program/FA/UW is the best option to really help you pinpoint those really high-yield topics and score well on the exam.

      I hope that helps. If you need to talk about this further please feel free to email me by going to the ‘contact us’ page and we can discuss things in greater detail so we can get you moving in the right direction.

      Dr. Paul

      • sukhpreet singh says : Reply

        Suppose a IMG student gets 250 + in step 1 and step 2 ck…..but has 1 repeat in step 2 cs… much chances are dere of him getting the residency in internal medicine….

  4. Paul Ciurysek, MD says : Reply

    Any failure on the exams will close a few doors, especially the CS… However, 250+ demonstrates that you definitely are a strong candidate and I’d imagine you will have a rather high chance for success with scores in that range.

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