How Important Is My Step 1 Score?

Sara Cohen, MD


June 12, 2012


I'm getting nervous about Step 1 because it seems so important for residency applications. Any suggestions for how to approach the exam?

Response from Sara Cohen, MD
Fellow, Department of Physical Medicine and Rehabilitation, Harvard University; Fellow, Department of Physical Medicine and Rehabilitation, VA Boston Healthcare System, Boston, Massachusetts

Step 1 is the first part of the United States Medical Licensing Examination (USMLE), traditionally taken after the preclinical medical school years as a standardized way to assess students' grasp of concepts fundamental to medicine. It's a single-day, 7-hour computerized examination consisting of more than 300 multiple-choice questions.

Students receive a 3-digit score that almost always falls between 140 and 260. The mean score varies from year to year but usually ranges from 215 to 235. A strong score on Step 1 is generally considered to be requisite for a competitive residency program.

First and foremost, don't panic over USMLE Step 1. Although Step 1 scores are important to certain highly competitive fields, for most specialties you can overcome a mediocre score with good grades, research experience, and strong letters of recommendation.

Conversely, a strong Step 1 score doesn't negate poor grades and mediocre letters. The National Residency Matching Program (NRMP) Website provides statistics on how important different factors are for residency consideration in each field as well as other match statistics, including Step 1 scores.

In my field of physical medicine and rehabilitation, for example, residency programs ranked letters of recommendation as 4.2 out of 5 in importance, Step 1 score as 4.1, and interactions with staff during interview/visit as 4.8.

Only 5% of programs will not consider a student who failed Step 1 on the first try. Alternately, if you look at the statistics for dermatology, one of the most competitive specialties in which to match, generally programs will not grant interviews for Step 1 scores below 221.

If you're interested in a competitive field or if you have your heart set on a more competitive program in a less competitive field, a good score on Step 1 is important.

In my school, the mantra was that your Step 1 score reflects your grades of the past 2 years. Students who received a Pass in all of their classes would get an average grade on the exam, whereas students earning Honors grades would generally get a very high Step 1 score. I found this to be true for myself and my friends.

Step 1 scores also tend to correlate with MCAT scores, as both require the ability to do well on large, standardized exams. Someone with a below-average MCAT score will rarely achieve a spectacular score on Step 1.

When and What to Study

Everyone has a different philosophy about studying, but because the exam tends to focus more on the pathology learned during second year of medical school, it's a good idea not to start studying until second year. But at what point during your second year you start studying is an individual decision.

Although I didn't start studying until late in the year, I tried to have the exam in mind during my second-year classes. I bought First Aid for the USMLE Step 1 (McGraw-Hill Medical) and made notes in the margins during my classes. (First Aid for the USMLE Step 1 provides a great outline of important material for the board and was purchased by nearly every member of my class.) At the end of each course during second year, I did USMLE-type questions in addition to my usual exam studying.

Depending on how much time is allotted between the end of second year and start of third year, some students may not start studying in earnest until the end of second year. Generally, a month is an adequate amount of time to prepare for the exam. It's important to make up a study schedule in advance, with extra emphasis on important topics and ones that are weaker subjects for you. The USMLE Website provides a full list of topics that are on the exam as well as a set of free practice questions.

Part of your exam studying should involve a QBank, an online bank of questions in the same format as Step 1. Several companies provide online QBanks, the most popular of which are Kaplan, USMLE World, and USMLE Rx.

The main thing you want to look for in a QBank is a large bank of questions (about 2000) in the same format as the exam, which is of equal or greater difficulty to the actual exam. There should also be a wide variety of questions on different subjects and detailed explanations.

If possible, take an entire simulated exam. Review services such as Kaplan provide a full-length exam as part of their QBank service, and taking these will tell you if you're studying at an adequate pace and give you a sense of what it feels like to take the actual exam. Taking the simulated exam about a week before the real exam will give you enough time to work on any deficits and it will be late enough to reflect the studying you've done.

Although the USMLE Step 1 exam score is important in residency applications, a low score is not the end of the world. Good letters of recommendation, grades, and interview performances can compensate for a subpar Step 1 score.

You might also consider taking Step 2-CK (clinical knowledge) early and demonstrating an improvement. Fortunately, in most residency programs the program directors take into account several factors in deciding which students to rank and will consider more than just a single exam score.


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