The Process of Applying and Studying for the USMLE Step 1

By Nawal Bokhari


The United States Medical Licensing Examination (USMLE) is a three-step examination taken by all US and international medical students to obtain a medical license to practice in the U.S. It tests your fundamental knowledge and skills and your ability to apply these concepts to provide effective and safe patient care.


The USMLE is split into three parts; Step 1, Step 2 CK and Step 3. The USMLE Step 1 is the first examination to pass in the journey to become a licensed physician in the U.S and arguably the most important, so what exactly is it?


The Step 1 mainly tests your basic science knowledge and your ability to apply foundational science concepts to clinical scenarios. It is an 8-hour Computer-Based Test consisting of a 15-minute tutorial followed by seven 60-minute question blocks of up to 40 multiple choice questions each, with no more than 280 questions in total. You then have 45 minutes break time which you can split up as you like. Currently, Step 1 examinees receive a three-digit numerical score based on the total number of questions they get right as well as a pass/fail status. At present, the pass mark for Step 1 is 194 which is approximated to be about 60-70%. However, from January 2022, Step 1 is changing from a numerical score to just pass/fail.


So that’s what the exam is, but how do you actually register for it and, most importantly, study for it? As International Medical Graduates (IMG), the process for applying for the USMLE is slightly different than that of US graduates. While US graduates register for it through the NBME, IMGs have to go through the Educational Commission for Foreign Medical Graduates (ECFMG) and eventually obtain an ECFMG certificate which allows you to enter residency and fellowship programs in the US. The whole process can be long and confusing, but these simple steps can guide you in applying for the USMLE Step 1.


The first step is to create an account on the ECFMG Interactive Web Applications (IWA) website. To do this you will need to request a USMLE/ECFMG registration number. Once you have this, you can log in to the IWA website and apply for the ECFMG certification which costs $150. Next, you need to complete and notarize the Certification of Identification Form. Once your identity has been verified you can complete the USMLE Step 1 application and pick a 3-month eligibility period during which you will choose to schedule your exam, so it is important you pick a period that is appropriate. The fee for the USMLE Step 1 is $975 and if taking the exam outside of the US or Canada there is an additional international test delivery surcharge of $180. Once the application is complete, your medical school will verify your status. You will then receive your scheduling permit which allows you to book a test date on the Prometric website.


Studying for the USMLE Step 1 is the most important and most difficult part in the whole process. It is vital to take your learning preferences into account when preparing for the Step 1. Before you start studying though, you need to create a timeline for study. I personally started studying for Step 1 during my third year of medical school and aim to take the exam this summer before I start fourth year. I have personally found that this is the best time for me to take the exam as I would have completed my basic science years as well as one clinical year. Since many of the questions in the exam are based on a clinical scenario, being in clinical years while taking the exam allows me to think clinically and apply my foundational science concepts.


The whole process can take months, so it is vital that you start planning well in advance. The best thing to do in studying for Step 1 is building upon the foundation of knowledge from the basic science years in medical school and there are many resources available to help you to do so.

The First Aid for the USMLE Step 1 textbook will be your holy grail. This textbook contains everything you need to know for the Step 1. While I didn’t begin studying for Step 1 until the end of second year and my basic science years, in retrospect, I would recommend buying this textbook, annotating and highlighting it throughout your basic science years in medical school. Not only will this help you with your medical school exams, but it will really help consolidate your knowledge and build a strong foundation. It is also the way that all US medical students study for Step 1, as they usually take it at the end of second year. I would recommend going through the First Aid textbook 2-3 times in total.


Another textbook which is great to use is Pathoma: Fundamentals of Pathology. About 45-52% of the Step 1 questions test pathology and is the biggest weighted discipline to be examined. Pathoma is one of the best textbooks on pathology and is great to use alongside First Aid. While there are many other textbooks available, these would be the only two that I would recommend as they cover and explain all the key concepts in the perfect amount of detail required.


Spaced repetition distributed practice is an excellent method of retaining information in the long term. Flash cards are the most simple and effective way of incorporating this into your study plan. The best app to use for this is Anki. While you can make your own flashcard decks, I found this to be very time consuming and I would spend more time making the flashcards than actually doing them. Anki has loads of online shared decks specifically for Step 1 which you can download and use. Some of the most popular ones include Zanki and Anking.


Practice testing is probably the most effective method of studying for Step 1 with great long-term benefits. The best question bank available for Step 1 is the UWorld Qbank. It provides you with a bank of 3489 questions as well as 2 practice exams. There are also more practice exams available from the NBME. While there are other question banks available such AMBOSS, USMLE-Rx and Kaplan, UWorld is by far the best rated and most popular as it is closest to the actual Step 1 exam.


On the whole, applying and studying for the USMLE Step 1 is a long, difficult and expensive process and requires a lot of commitment and is just the first step in an even longer journey. However, in the end the reward you receive from doing it makes it all worth it. I have found that it has helped me immensely throughout my medical school studies and is something that I would definitely encourage all medical students to consider. I would highly recommend taking time out to plan the whole process, many people take months of dedicated study to prepare for it. You have to remember that doing the USMLE is a marathon and not a sprint.

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