The USMLE: Ten Questions

Medscape General Medicine 


With the dreaded USMLE Step 1 now always around the corner -- it's now given 6 days a week, every week! -- the test has become a popular topic of questions on Medscape Med Students' discussion boards. I decided to go straight to the source for some answers, so here's a Q & A with Chirag Amin, MD, and Tao Le, MD, 2 of the authors of that USMLE bible, First Aid for the USMLE Step 1 2001: A Student to Student Guide. Dr. Amin is now Vice President of Content and Community for, where Dr. Le is Chief Medical Officer.

Medscape: Describe the USMLE.

Drs. Amin and Lee: The USMLE Step 1 computer-based test (CBT) is a 1-day test, taken on a computer, that's administered once a day (except Sunday) on a year-round basis at hundreds of testing centers around the world. The test consists of a total of 350 multiple-choice, single-best-answer questions that are broken down into seven 1-hour blocks, with 50 questions per block. Examinees are given short breaks between blocks, as well as a lunch break.

M: How long in advance of Step 1 should students start preparing? Should they make studying for the USMLE a part of studying for regular courses?

A&L: The USMLE Step 1 was designed to assess medical science knowledge and concepts taught during the preclinical years at a typical medical school. Therefore, medical students who studied diligently during their first- and second-year coursework end up minimizing the stress and workload of a USMLE Step 1 review. Regardless, most students start intensive examination preparation on a full-time basis (ie, 6-8 hours of studying per day) approximately 4-6 weeks before the actual examination date. Due to differences in their medical education/training and curriculum as well as the time that often lapses since the completion of basic science coursework, international medical graduates (IMGs) usually need 2-4 months of study before taking the USMLE Step 1.

M: If you have a month, as many schools give students, what's a good schedule?

A&L: In the month leading up to the exam, the majority of medical students find themselves studying anywhere from 6-12 hours each day, dividing their study time proportionally over the 7 traditional basic science disciplines, which include anatomy, behavioral sciences, biochemistry, microbiology/immunology, pathology, pharmacology, and physiology. In addition, many students devote the last week of their exam preparation to comprehensive review as well as going through sample questions. Many students recommend thorough review of the high-yield facts in First Aid for the USMLE Step 1 during the last week. Generally, students devote more time to the more clinically relevant disciplines, such as pathology, pharmacology, and microbiology/immunology. However, a common mistake that students make is not spending enough time covering all subject disciplines thoroughly.

M: What books can you recommend for general review? For specific subjects?

A&L: Students usually find themselves buying anywhere from 10-25 review as well as question-and-answer (Q&A) books, but most will start with our First Aid for the USMLE Step 1. The major medical publishing companies such as McGraw-Hill, Lippincott Williams & Wilkins, Blackwell Science, and Harcourt Health Sciences have several excellent titles for USMLE review. In addition, many students have benefited from books that present this basic science material from a clinical perspective, such as our Underground Clinical Vignettes series.

M: What kind of surprises, in terms of subject material, have students told you about?

A&L: Many medical students that we have talked to underestimate the amount of clinical material on the USMLE Step 1 examination. For example, a significant portion of the anatomy that is tested on the USMLE exam is based on one's ability to recognize anatomical structures on common radiographic images, such as x-rays, CT, and MRI scans. Furthermore, many students also leave the exam feeling somewhat intimidated regarding the clinical slant of how the basic science material is tested. Knowing specific disease pathophysiology as well as drug mechanism of action in the context of a clinical scenario is essential for doing well on the USMLE.

M: Do courses work?

A&L: This depends on the student's learning style and level of discipline. Only a small percentage of students take a review course for the USMLE Step 1 examination. Many students feel that they can benefit more by organizing a study schedule that is focused around their own strengths and weaknesses. However, there are some students who are not effectively able to manage their own study time. Those students may benefit from a structured review course.

M: What about cramming?

A&L: Because the material tested on the USMLE Step 1 examination covers a large amount of information that is learned over the course of 2 years in medical school, strict cramming is usually not an effective method for USMLE preparation. Furthermore, since many questions on the exam are asked from a clinical standpoint, requiring medical reasoning and problem-solving skills, a structured and disciplined review over the course of several weeks is far more effective in terms of doing well on the exam as compared to cramming. That being said, anecdotes abound about medical students passing just by cramming First Aid for the USMLE Step 1. Again, cramming is not recommended.

M: What kind of advice do you have for international medical graduates?

A&L: The most important advice for international medical graduates is to become familiar with taking exams on the computer. The vast majority of international medical graduates have never taken an exam on the computer, and this is a major obstacle. Factors such as eye strain and mouse dexterity can serve as a major obstacle when taking the examination. The more that one is able to become familiar with the specific test-taking environment, the better that person is able to concentrate on the test itself.

M: Any particular advice for students who are retaking the exam after failing?

Honestly assess your weaknesses and shortfalls in your previous exam preparation, and focus on improving in those areas. Retakers have the advantage of experience, and most use this advantage to their benefit in terms of revising their method of exam preparation when studying the second time around. The good news is that retakers generally have a very high pass rate.

M: Can you list helpful resources?

A&L: There are a number of helpful resources for USMLE preparation. In terms of textbooks, one textbook that gives an excellent overview of the exam, including a database of high-yield facts and a detailed list of useful resources, is our First Aid for the USMLE Step 1. Many students consider this book the best place to start their exam preparation. In addition,'s community Web site ( has a USMLE Study Center that provides a wealth of free information, including online USMLE lectures, sample training schedules, simulated exam modules, recommended books, discussion forums, and much more. Another important resource is the National Board of Medical Examiners (NBME) Web site at, which provides students with the most up-to-date information about the examination.