All Your USMLE® Step 1 Questions Answered: The Osmosis Ultimate Guide

USMLE® Step 1 is the first major exam medical students take on their path to becoming a doctor. This 8-hour exam is designed to assess your understanding of concepts in pathology and physiology. In the past, the exam was scored on a numerical basis, but since 2022 it has become pass/fail. Nevertheless, it's important to do well on this exam—and All About USMLE Step 1: The Osmosis Ultimate Guide will show you how to do just that!

Contents

• Introduction

• What’s on the USMLE Step 1 exam?

• USMLE Step 1 test scores & exam duration

• What's the best way to study for USMLE Step 1?

• The Osmosis Learning Loop

• USMLE® Step 1 exam logistics: What you need to know for the big day

• What should I expect after I take USMLE® Step 1?

• What happens if I fail Step 1?

• How has COVID-19 impacted Step 1?

• How can Osmosis help me study for USMLE® Step 1?

• Ace USMLE® Step 1 & beyond with Osmosis resources

Introduction

No doubt that since you got into medical school, or even before you started medical school, you’ve heard how important the USMLE Step 1 Exam is. This is the first board exam you’ll be taking on your journey to becoming a full-fledged physician—and the stakes are high.

Until recently, your score had a huge influence on what your residency, specialty, and overall career options could be in the future. In fact, 94% of program directors stated that a candidate’s score on USMLE Step 1/COMLEX-USA® Level 1 was the most important factor when offering a prospective residency interview.

Now that the USMLE Step 1 has moved to pass/fail, less emphasis is placed on this exam; instead, program directors will be more focused on things like your USMLE Step 2 CK score and performance during your clerkships

Nevertheless, passing Step 1 is essential if you want to continue learning medicine, and for now, it remains the most high-pressure exam you’ll take on the road to residency.

No big deal, right?

Well, take it from us: you’re completely capable of passing this exam and getting a high score. You are a medical student: you’ve come this far, and with the right plan, you’ll make it all the way. Osmosis has your back!

In this guide, we’ll be covering everything (and we mean everything) about USMLE Step 1, including:

• What’s covered in Step 1?
• How should I study for Step 1?
• How do I apply to take Step 1?
• When and where should I take Step 1?
• What Step 1 score do I need to match for residency?
• What happens if I fail Step 1?
• How has COVID-19 impacted Step 1?
• How do students use Osmosis to study for Step 1?

Now, without further ado, let’s get started with the most fundamental question to help you prepare for Step 1: What’s on the USMLE Step 1 exam?

What’s on the USMLE Step 1 exam?

Step 1 is a multiple-choice computerized test that you’ll take at a designated exam center. The exam is divided into seven “blocks,” each containing up to 40 questions that will test your medical knowledge and your analytical skills. You will have one hour to complete each “block.”

What skills will the Step 1 exam test me on?

In general, USMLE Step 1 will require you to:

• Utilize your understanding of basic scientific principles to solve clinical problems
• Analyze and interpret data (graphs, tables, oscillation media, etc.)
• Recognize both normal and pathological processes from gross and microscopic specimens.

What topics are covered on Step 1?

USMLE Step 1 covers a range of didactic topics, and evaluates you on a series of physician tasks and competencies as well:

How are different topics weighted on USMLE Step 1?

Test items are divided into Systems and Processes as follows:

USMLE Step 1 test scores & exam duration

What score do I need to pass Step 1?

On February 12, 2020, the NRMP announced that scoring for USMLE Step 1 will be changed to pass/fail. The transition from numeric scoring to pass/fail began with exams taken on or after January 26, 2022. To learn more, visit USMLE.org.

How long is the Step 1 exam?

The whole Step 1 exam takes about 8 hours, broken down as follows:

• Tutorial: 15 minutes (optional—more on that later)
• Breaks: 45 minutes
• 7 Testing blocks: 60 minutes per block (~1.5 minutes per question)

There are some nuances around breaks that we’ll cover in more detail in the Step 1 Logistics section later in this article.

What's the best way to study for USMLE Step 1?

Now that you have a sense of what you’re going to be tested on, it’s time to come up with a strategy for how you’re going to learn all this information for the exam.

Studying for Step 1 isn’t like studying for any other exam you’ve taken. You need to know two years’ worth of medical school information inside and out. Solidifying your knowledge of this gargantuan amount of complex information requires a game plan.

1. Develop effective learning habits

Learning is a science, and there are many proven techniques that will make your life a whole lot easier in the lead-up to Step 1. Osmosis Research Director Dr. Sean Tackett developed a full course on learning science. How to Learn in Medical School helps students become better learners using six proven learning science techniques:

1. Testing effect
2. Spaced repetition
3. Interleaving
4. Multimedia learning
5. Elaborative interrogation
6. Concrete examples

A little note on Spaced Repetition

Spaced repetition is a big part of why learning by Osmosis is so effective. But what is spaced repetition and how does it work?

Spaced repetition is the act of retrieving knowledge at increasing intervals to reduce forgetting and enhance long-term learning. Essentially, you’re reviewing information repeatedly over time to burn it into your long-term memory.

Timing this manually can be difficult, which is why technology-enhanced learning is so effective. The Osmosis platform uses a spaced repetition algorithm to test you on key information at optimal times to aid memory retrieval and help you build a knowledge foundation that will last for a lifetime.

2. How to pick a few good resources and stick to them

There’s a glut of study resources out there for Step 1, and it can be tough to find the right fit. Some students will oversaturate themselves with resources—this trial and error process can mean a lot of wasted time early in the study period. So how do you choose?

The UFAP study resources (UWorld®, First Aid®, Pathoma®) are great, but UFAPO—combining the resources with Osmosis—is even better. Think of Osmosis as your HQ and right-hand person for this momentous challenge ahead of you. All of the UFAP resources can be integrated into the Osmosis Study Schedule for a completely seamless learning experience that covers all of your bases.

With Osmosis, you’ll also have the additional support of our extensive video library, which brings to life the topics covered in First Aid and UWorld’s question explanations—allowing you to have a better grasp of the material and be more confident on the day of your Step 1 exam.

These videos cover important topics like basic sciences, biostatistics, epidemiology, pharmacology, microbiology, pathology, physiology, and more. Once you’ve watched the pathology videos, you can kick your studying into high gear with our new High Yield Pathology series, which has been specifically designed to highlight all of the important concepts needed for the USMLE Step 1.

Additionally, Osmosis also has 3,000+ USMLE Step 1-style practice questions on pre-clerkship subjects including pathology, anatomy, physiology, microbiology, and pharmacology. As of December 2022,  the Osmosis medical assessment team completed a thorough audit of thousands of board-style questions, with the goal of reviewing to ensure that every question is patient-first, inclusive, and aligned with what students need to know to be successful on your board exams.

Additionally, Osmosis also has flashcards, questions, and High-Yield Notes that can further assist you in your mastery of your preclinical knowledge.

Every learner will take a different approach with regard to how they use these resources. In our next section, we’ll go over some general tips to steer you on the right path.

Start reviewing early

The sooner you start studying for Step 1, the better. You should be regularly reviewing concepts you’ve already learned throughout the year to ingrain them into your long-term memory. This will save you time during your dedicated study period, as you’ll already be building on a strong base of knowledge.

Some students like to start studying very early on and take a practice exam before their dedicated study period begins. NBME self-assessments will highlight your weak areas, giving you a better idea of where you should focus your studying.

Go through each resource as many times as you need

A quick Google search will reveal endless Step 1 prep strategies from students—you have to pick what’s right for you. A general rule for knowing if you’ve studied a topic enough is to try explaining the concepts to someone. If the information comes easily, you’ve learned it; if you find yourself struggling, you still have work to do.

Focus on classical presentations of diseases

When you’re studying pathology for the exam, focus specifically on the typical presentations of diseases, as the exam will only test you on these. If you try to think about all the possible ways a condition can manifest, you will end up overthinking things and potentially trip yourself up. Familiarize yourself with the basics and trust your gut.

Stop studying when you feel you’re running out of steam

If you’ve been studying for over 10 hours and feel like things just aren’t sticking anymore, chances are, they aren’t. You might have a classmate flexing about pulling regular all-night sessions, but you don’t know how much of that time is actually productive.

Some students feel “guilty” about taking study breaks. If it helps, consider breaking up your study periods with other “productive” activities, like exercise or meal prep. Whatever you do, step away from the books, and close your computer—you need this time to absorb the knowledge you’re trying to retain. It’s all part of the process!

Don’t panic if you see a classmate using a resource you’re not using 

As we’ve mentioned already, everyone will take a slightly different approach to learning for Step 1. Find the resources that work for you, and stick with them.

3. Learn how to break down USMLE-style practice questions

Knowing your systems and processes inside and out is just one aspect of studying for Step 1. You’ll also need to be familiar with how USMLE® questions are structured so you can quickly eliminate incorrect answer options and make the best choice.

Osmosis has several resources that show you how to develop the right mindset to ace Step 1 questions:

• How to Ace Med School & The USMLE with Dr. Maddison Caterine
  
  
• Breaking Down USMLE Step 1 Questions with Dr. Justin Ling
  

When you’re done with these resources, try putting your learnings into action with the Osmosis Q-Bank, which contains more than 3,00+ Step 1-style practice questions.

→ Get started with the Osmosis Question Bank.

4. Make effective use of flashcards

 Flashcards are a convenient way to learn a high volume of information quickly. They’re best suited for learning individual facts rather than interconnected concepts, and they’re a great way to study on the go.

Osmosis Prime has over 16,500 flashcards built into the platform, all containing information you may need to know for Step 1. You can also build your own flashcard decks on Osmosis using the Flashcard Builder. An added bonus: Osmosis automatically works spaced repetition into your flashcard queue, delivering a method for reviewing concepts that are based on learning science.

5. Practice multimedia learning

Multimedia learning is when you incorporate written, visual, and audio materials into your learning. This is the essence of learning by Osmosis!

When you learn from a variety of sensory stimuli, that information is processed into smaller “bits” which become part of your working memory. Combining the words you read and listen to with visual images helps your working memory process them together as integrated “chunks” which moves the concepts into your long-term memory more efficiently and forms stronger links with information you’ve already learned.

The Osmosis Learning Loop

Studying for USMLE Step 1 with Osmosis allows you to harness the power of multimedia learning to gain knowledge that will stick with you long after you've taken the exam. Make the most of it using these resources and practice the Osmosis Learning Loop:

• Watch a video
• Go through the flashcards
• Test yourself with practice questions
• Review with High-Yield Notes

6. Take practice exams

For a $75 fee, you can visit your local Prometric test center and take a short practice test in the same environment that you’ll take the actual Step 1 exam. These practice tests are shorter than the exam you’ll take on test day, clocking in at around 3.5 hours, but they’re a good way to familiarize yourself with the exam setting. To learn more and register, visit the USMLE website.

Step 1 is a long examination, and you need to go in prepared to deal with what can be a physically and mentally exhausting experience. To get a feel for this, you should try to simulate the test environment with at-home practice tests before you take the exam.

The NBME’s comprehensive self-assessments will help you identify key areas you need to focus on to improve your score. Typically, they’re about 4 hours long—doing two of these back-to-back is grueling, but good training for test day.

→ Learn more about NBME self-assessment services.

A note about NBME practice tests: many students obsess over their practice test scores and cause themselves undue stress. Think of this as a practice run, not an exact predictor of your Step 1 score.

When should I take my Step 1 practice tests? 

Every student will approach practice tests differently. There are a range of approaches, and you should do what works for you. Some students may take a practice test every 2–3 weeks during their dedicated study period, including one at the Prometric test center.

Whatever your approach, try to take a practice test at least a month before the actual exam. This way, if you don’t get a score that is within the range you want, you’ll have time to reevaluate your goals and rethink your strategy with minimal stress.

The Osmosis Step 1 Study Schedule will automatically integrate practice exams into your schedule if you create one during the dedicated period, which ranges from 4-8 weeks from your test date. The platform will pick the optimal days for you to take your practice tests.

Are you a little further out from your test date, or maybe you don’t have a date selected yet but still want to incorporate some practice exams into your schedule? The Step 1 Study Schedule allows you to input these dates manually, along with other resources (question banks, books, and videos).

7. Maintain healthy habits in the lead-up to the big day

Keeping a healthy routine should be part of every study plan. Physical and mental self-care is crucial for thriving in every stage of your medical education, but the months, weeks and days leading up to your first board exam are particularly stressful. Here are a few quick tips for maintaining equilibrium and managing any last-minute exam-day jitters so you feel fully ready to crush Step 1 on test day. And remember: test anxiety is a real (and solvable!) problem that many students face. Check out our two-part webinar on the topic, and always feel empowered to ask for professional help if you need it.

Take study breaks

Taking a break will give your brain time to absorb the information for the long term. Once you see your productivity levels starting to flag, it's time to step away from the books and do something else, even if it's just for a few minutes. Check out these study tips from Osmosis learners and the team for more information on the value of breaks, plus advice on how to optimize your study space for maximum productivity, and more:

• How to maintain productivity in the midst of uncertainty
• Finding inner peace during a time of turmoil

Make sure to exercise

Physical exercise has positive benefits for cognitive performance. It’s also a great way to blow off steam (and manage anxiety). Osmosis learners Abe Baker (University of Illinois College of Medicine, Rockford) and Percy Takyi (Philadelphia College of Osteopathic Medicine) both watch Osmosis videos while they exercise!

• Multitasking with Osmosis
• Establishing Balance in Medical School
• Try This No Equipment At-Home Workout for Students in Quarantine

Eat a healthy diet

When it comes to Step 1 studying, ramen noodles aren’t going to cut it. You need to eat real brain food. Eating a healthy, balanced diet of green vegetables, whole grains, and lean proteins will keep you alert and focused.

• 5 ways to get your health back on track
• How to meal plan in medical school

Maintain a regular sleep schedule

Proper sleep hygiene is important. Going to bed at a consistent time every night will keep your brain well-rested, which helps strengthen connections between ideas.

While it might be tempting to sneak in a few flashcards on your phone before bed, try to avoid doing this. Stop studying, switch off, and avoid screens at least an hour before bed.

Establish a support system with friends and family

Maintaining relationships is challenging during medical school, especially during your Step 1 study period, but it’s very important for your mental well-being. Whoever you choose to be part of your support network, make sure to stay in regular contact with them. Having someone to cheer you on as you reach towards your goals is incredibly motivating!

Celebrate important study milestones

Studying for Step 1 is like a marathon—you have to pace yourself! And every once in a while, that means taking a study break. Small goals are worth acknowledging, and it really helps to have something to look forward to at the end of a period of dedicated review.

Stop studying the day before the exam

Now, this one might be a little controversial for die-hard USMLE preppers. But hear us out.

Dedicate the day before the exam to getting yourself into the right headspace. Relax, recharge, and take care of last-minute housekeeping tasks, like figuring out how to get to the test center, checking the weather, and preparing your snacks.

And, as a reminder, go to bed on time!

USMLE Step 1 exam logistics: What you need to know for the big day

 Now that you’re familiar with what’s on the USMLE Step 1 exam, how to study for it, and how to mentally and physically prepare for it, it’s time to look at practical details, like registering for and taking the exam.

How do I apply to take Step 1 as a US Student?

To register for the exam you’ll need to visit the NBME® Licensing Examination Services website, input your information, and pay a $645 registration fee. You’ll then need to coordinate with your institution to have your documents sent to the NBME head office for processing.

After you receive your email confirming your three-month testing window, head to the Prometric website to schedule a specific date.

How do I apply to take Step 1 as an International Medical Student?

If you’re an International Medical Student (you attend a medical school outside of the U.S. and Canada), you’ll have to register through the Educational Commission for Foreign Medical Graduates (ECFMG®).

Can I reschedule my Step 1 exam date if I need to?

 Yes. 31 days or more from your scheduled exam date is free, closer to the exam incurs a fee. Get the specifics here.

When should I take Step 1?

U.S. medical students typically take Step 1 in April, at the end of their dedicated study period, but it varies by institution. Some students don’t take it until the third year, when they’re in the midst of clinical rotations!

International students will often take Step 1 during the summer between their preclinical years and the start of clerkship (e.g. the summer after the second year in a four-year program), or after the fourth year in a six-year program.

Whenever you end up taking Step 1, make sure you give yourself plenty of time for review. Programs vary in their allotted Step 1 dedicated period for students. We do recommend beginning your prep 3-6 months before your exam, but on average, 5-8 weeks (or 40 dedicated days, not including weekends or break days) is the recommended amount of time for a dedicated study period. However, now that Step 1 is pass/fail, you may need even less time for a dedicated study period (and programs may subsequently move toward allotting shorter dedicated periods for students).

Where do I take Step 1?

USMLE Step 1 exams take place at Prometric test centers around the country. To find where your nearest test center is, plug your ZIP code into Prometric’s website, and be sure to save Prometric’s Closures page, which is updated daily with any temporary closures due to extreme weather, technical issues, pandemic impacts, or other circumstances. COVID-19 impacted Prometric test centers, but they've reopened for essential tests.

What can I expect on test day?

You need to show up for the exam at least 30 minutes before the scheduled time to check in. If you’re late, you won’t be allowed to take the exam. Bring a government-issued ID with a name that matches your scheduling notification.

The exam center will provide you with a temporary locker for your belongings, which you can access during your breaks. You’re not allowed to bring anything into the exam room with you, save for your ID, locker key, and soft earplugs, and noise-canceling headphones provided by the test center.

Items like eyeglasses will be inspected to check for cameras, and all jewelry, with the exception of wedding rings, is forbidden. Empty your pockets, and prepare to be scanned with a metal detector before entering the exam room.

What is the USMLE Step 1 exam room like?

In a typical scenario, you’ll enter an exam room that looks like an office space. There will be cubicles with individual computers. You’ll be told which is yours before entering the exam room. If you experience issues with your assigned computer, inform staff immediately.

What is the USMLE Step 1 test interface like?

The USMLE Step 1 test interface is pretty simple—you can check out a working version here. We’ve also put together this image highlighting the basic features and their functionality.

How do breaks work during the USMLE Step 1 exam?

USMLE Step 1 test-takers are entitled to 45 minutes of break time throughout the course of the exam. You can take up to six breaks (i.e. one break between every testing block). You cannot break in the middle of a block.

How you use your break time is up to you. Some test-takers will take a break every block, while others will take a longer break every two blocks. If you finish a block early, you can leave the exam room, and that time will be added to your break period.

You can also add to your break period by skipping the 15-minute tutorial session at the beginning of the exam. Test-takers can do the tutorial at home before heading to the test center. If you’re familiar with NBME practice exams (and you should be!) or platforms that use a similar interface, like UWorld, you should also be fine to skip the tutorial.

What should I bring with me to the Prometric test center?

Bring a water bottle and some light snacks to eat between test blocks. Avoid a full lunch, as it could make you sleepy. We recommend healthy foods that will give you quick energy boosts, like:

(Note: When you leave the exam, don’t forget to bring the slip provided by the test center that proves you took the exam—if anything, it’ll serve as a reminder that the whole experience was real!)

I have a disability. Can the Prometric test center accommodate my needs?

Yes, accommodations can be made for people with physical and learning disabilities, provided the applicant provides full documentation regarding the particularities of their circumstances. You’ll need to fill out an application form and provide a personal statement and copies of professional assessments.

For a full list of what you need to do to get started, visit the USMLE test accommodations page.

What should I expect after I take USMLE Step 1?

When will my Step 1 results arrive?

Results are usually available in 3–4 weeks, but delays do occur. The USMLE says to allow at least eight weeks for notification that your score is available. You can find announcements about any potential delays here. If possible, try to use this time to relax and recharge. You’ve earned it, and at this point, you’ve done everything you can!

What happens if I fail Step 1?

Unfortunately, some students do fail Step 1 (or the other Step exams) each year. It’s not the best of circumstances— even if you score high on a subsequent attempt, the fact that you failed can impact your residency applications, as there are far more applicants than available residency positions.

If you fail Step 1, the first thing you should do is take a deep breath: this isn’t the end of your journey, and it’s going to be okay. Take time to examine and accept your feelings, and then look ahead to the future.

Next, tell your advisor. They will help you come up with a recovery plan, delay your clinical rotations if necessary, and arrange a second attempt. Remember to thank your advisors for their help!

When you’re studying for Step 1 the second time, assess your previous study strategy and adapt. Avoid spending too long on any one subject, and focus on what you don’t know, rather than topics you’re already confident in. Use practice tests to identify your areas of weakness and double down on them to build a more well-rounded knowledge base.

→ Learn more about Overcoming Failure in Medical School.

Step 1 isn’t the sole measure of your worth as a residency applicant and future doctor. There are other factors, including:

• Writing a compelling personal statement
• Working on a compelling Curriculum Vitae
• Sourcing great letters of recommendation from your mentors
• Nailing your medical school interviews
• Publishing research
• Demonstrating strong academic performance
• Showcasing your work and volunteer experience
• Having a graduate degree

How can Osmosis help me study for USMLE Step 1?

Studying for Step 1 is one of the biggest challenges you’ll face as a medical student. We know because we’ve been there. Osmosis was founded by medical students for medical students. It’s designed to take all the complex information you’re expected to know in medical school and make it manageable—not just for Step 1, but for the rest of your education, and in your career.

Check out these success stories from Osmosis learners:

Ace USMLE® Step 1 and beyond with Osmosis resources

Osmosis gathers all the resources you need to stay organized and study more efficiently for the USMLE® Step 1 and Step 2 CK in one place. Get access to:

• 1,600+ Osmosis USMLE® videos offering comprehensive coverage of pathology, physiology, pharmacology, and anatomy, as well as High-Yield Pathology Review videos for dedicated Step 1 prep
  
  
• 4,700+ USMLE-style case questions
  
  
• 16,000+ USMLE-style flashcards
  
  
• Dedicated USMLE Step 1 Study Schedule
  
  
• High-Yield Pathology & Physiology Notes

And so much more!

Osmosis also aligns with your favorite USMLE® resources and study tools, including:

• First Aid
  
  
• Pathoma
   
• UWorld
   
• SketchyMedical
   
• Picmonic
   
• Boards and Beyond

Better manage your studying with Osmosis and ace the USMLE®. Try it free today.

The United States Medical Licensing Examination (USMLE®) is a joint program of the Federation of State Medical Boards (FSMB®) and National Board of Medical Examiners (NBME®). Osmosis is not affiliated with NBME nor FSMB.