The United States Medical Licensing Exam is one of the most important exams for doctors seeking to practice medicine in the United States. Passing all three exams grants one the licensure to practice freely. Consequently, this has caused the exam to be labelled as difficult, with Step 1 gaining the worst reputation, which is an unfortunate mindset to have as Step 1 is the first exam that must be taken on your journey to licensure. In this article, we will take a closer look at the exam, pass rates of previous examinees, reasons why Step 1 has such a negative reputation, and how you can overcome it.
Overview of the USMLE Step 1
USMLE Step 1 is a gruelling eight-hour exam designed to test the breadth of your basic science knowledge and how well you can integrate that knowledge in a clinical setting. The computer-based exam features up to 280 multiple-choice questions spanning anatomy, pharmacology, physiology, microbiology, biochemistry, and behavioural science. Unlike later steps, Step 1 emphasizes integration: Can you connect biochemical pathways to disease symptoms or drug mechanisms to patient outcomes?
Typically, U.S. and Canadian medical school graduates take the exam after completing their foundational years, but before they begin clinical clerkship. However, in recent years, more medical schools have restructured their curricula and shifted the exam to follow early clinical training, aiming to bridge theory and practice.
Is Step 1 Hard?
Like many things in life, the answer to this question is subjective. Many people who have taken the exam reported that it was difficult and draining, but in 2020 and 2021, the pass rate for first-time examinees was 98% and 96% for students of U.S. and Canadian schools and 87% and 82% for those from foreign schools.
The truth, however, is that the difficulty majorly came from the pressure students put on themselves to pass the exam. Historically, the scores of Step 1 were used by residency programmes to decide who they would select for residency interviews. Knowing this, students, in a bid to score high, would increase their study period up to 16 hours a day for weeks on end. Many would skim through the medical school curriculum and pick out certain ‘high-yield’ topics to focus on, neglecting other parts. This practice caused many students to burn out and raised widespread concern about the mental health of examinees.
In 2022, Step 1 transitioned from a three-point scoring system to a pass/fail one and increased the pass mark to 196. The change was made to encourage examinees to shift their focus from high-stakes testing to learning and individual improvement. After the change, the pass rate for the 2022 and 2023 examinations dropped to 93% and 92% for first-time examinees of U.S. and Canadian schools and 74% and 72% for first-time foreign students. Not to worry, while part of the dip is attributed to the increased pass rate, another factor to consider is the lingering impact COVID-19 had on education and logistics. Pandemic-related challenges, like closed testing centres and interrupted clinical rotations, left many students underprepared.
Another reason for Step 1’s reputation as a difficult exam is the wide range of content covered, which requires examinees to learn, memorise, and recall detailed facts and trivial points. The exam is eight hours long with no scheduled breaks, and many people struggle with maintaining intense focus for that length of time.
Common Complaints About Step 1
Time Management Issues
One thing most people agree on after taking Step 1 is that the clock is a silent adversary. Seconds fly by as you carefully try to read through the question stem for clues. This loss of time causes anxiety and may lead you to miss clues that would guide you to an answer.
Fatigue and Mental Exhaustion
Maintaining intense focus for a prolonged period can be very taxing on a person, and not many people can hold that level of focus for 8 hours. Towards the back half of the exam, many people begin flagging and experience mental exhaustion.
Ambiguous Questions
Many past test takers reported that some questions were so vague that you’ll wonder if the exam tests your medical knowledge or psychic abilities. Two answer choices might seem right, and you’re left guessing. These questions test a skill less emphasised in prep materials—reasoning under uncertainty.
Stress and Anxiety
Despite many hours of practice and mock recreations of the exam, many test takers agree that the actual exam is more stressful. Various factors, such as being in an unfamiliar space with strangers around you, can cause you to feel unsettled and anxious. Plus, the realization that the event you had been preparing for during many months has arrived could be jarring.
Ways to Prep for Step 1
Master Concepts Over Memorization
The shift to pass/fail hasn’t made Step 1 easier—it’s made how you study more critical. Rote memorization is a trap; instead, focus on understanding mechanisms. Why does a blocked enzyme in a metabolic pathway cause specific symptoms? How does a drug’s pharmacokinetics influence its side effects? Test-takers who prioritized conceptual understanding often found they could tackle even the vaguest questions. Remember, you probably don’t understand if you can’t explain a concept in your own words.
Leverage Question Banks—But Strategically
CanadaQbank remains one of the gold standards, and UWorld is another. Remember, it’s not about quantity—it’s about quality review. Treat every question like a clinical vignette. After each block, ask: “Did I get this right for the right reason?” Flag your guesses and ruthlessly review those topics. Pair your Qbank with Anki decks like AnKing for spaced repetition of high-yield facts. You can attempt 40 CanadaQbank questions daily, then spend twice as long reviewing explanations. By test day, you should be able to recognise patterns, not just answers.
Simulate the Real Deal—Including the Pain
You wouldn’t run a marathon without training, right? Practice exams aren’t just diagnostics—they’re stamina trainers. Veterans of Step 1 stress taking NBMEs under timed, exam-like conditions. Why? The real challenge isn’t just knowledge—it’s enduring eight hours of focus. Past examinees have warned about how they aced other Qbanks but panicked during their first NBME because they had never sat for four hours straight. Take full-length practice tests under real conditions: wake up early, wear comfy clothes, and no unscheduled breaks. Hate anatomy? Too bad. Skipping it is like showing up to a gunfight with a butter knife.
Protect Your Well-Being: This Isn’t a Sprint
Burnout is the silent killer of Step 1 prep. Med School Insiders and past test-takers beg you to stop pulling all-nighters as your brain files away info while you sleep. Aim for 7-8 hours of sleep. Move daily; a 20-minute walk can reboot your focus. Yoga, dancing, screaming into a pillow—do whatever keeps you sane, and mute peers who humblebrag about their unsustainable study days. Build a self-care routine: meal prep, meditation, or whatever keeps you grounded. Remember: A tired brain misses clues.
Address All Subjects—Yes, Even Anatomy
The exam’s breadth is notorious, but conducting comprehensive prep is non-negotiable. Use resources like SketchyMedical for visual learning in microbiology and pharmacology, and Pathoma for pathology deep dives. Students often skip subjects like Ethics and Biostatistics, only to come across questions on them during the exam.
Manage Stress Like a Pro
Anxiety is inevitable, but it is manageable. Techniques like box breathing (inhale for 4, hold for 4, exhale for 6) can steady nerves during the exam. Practice them during mock tests to build muscle memory. Finally, apps like Headspace or Calm aren’t just for hippies—they can help you manage your stress and anxiety with actionable advice. And if you’re drowning, talk to someone—a friend, a counsellor, or your dog.
