Medicine From The Trenches

Experiences from undergradute, graduate school, medical school, residency and beyond.

Preparing for USMLE (United States Medical Licensing Exam)

Medicial students (allopathic) who attend medical school in the United States will typically take the first step of the United States Medical Licensure Examination (USMLE Step 1) in the summer between their second and third year. This examination tests the pre-clinical science subjects and is supposed to test the readiness of a medical student for entering their clinical clerkships during third year. Students must register

This examination, along with USMLE Step II Clinical Knowledge and USMLE Step III are given on computer in a Thomson-Prometric Testing Center. Once you are eligible for each step, you may register and schedule these exams on a day of your choice. USMLE Step II Clinical Knowledge tests a medical student’s readiness for the supervised practice of medicine i.e. internship. Most medical students in the United States will take this exam at some time during their fourth year. Step III is usually taken after graduation from medical school with application for permanent medical license at the time of Step III. Some states have a seven-year rule in that you must take and pass all three USMLE steps within seven years of taking USMLE Step I so keep your dates and years in mind. Optimally, get Step III out of the way as soon as you can.

In addition to USMLE Step II Clincal Knowledge, there is a USMLE Step II Clinical Skills (USMLE Step II CS) that must be taken. This Clinical Skills exam has been required of all graduating medical students since 2005. This exam is also staken during fourth year as it usually involves some travel to a specified testing center, Atlanta, Chicago, Los Angeles, Philadelphia and Houston on a specified date and hotel accomodations unless you have friends in this city that will put you up.

Now, for the “nuts-and-bolts” of USMLE Step I: First of all, the test is intergrated which means that each question block has subject matter from your all of your pre-clinical courses. The questions may test a specific type of subject matter but there are intergrated questions throughout the test. This means that you probably should not study for this test in a “subject-specific” manner but rather intergrate the materials. For example, a virus might attach the heart muscle and cause a myocarditis that leads to biventricular heart-failure. This may be presented to you in a case-scenario but you have to know the physiological and pathological effects of heart-failure along with the effects of myocarditis. This is why memorizing individual questions or attempting to study before you are done with your coursework is counter-productive.

Another popular USMLE Step exam technique is to ask secondary learning questions. A scenario might go like this: “A , neat and well-dressed young man comes to the office of your psychiatric practice. He states, ‘ I don’t know why I am here but I came anyway. My friends seem to think that I have a problem but I don’t think or see that I have a problem. It’s just that when I see something out of place, I feel compelled to put it back in its place. I like things neat and orderly.” A likely diagnosis for this patient is: A. Schizophrenia B. Acrophobia C. Obsessive-Compulsive Personality Disorder D. Obsessive-Compulsive Disorder.

In order to answer this question, you have to know something about the characterictics of the disorders in the answer choices and be able to differentiate between them. You also need to READ every answer choice and make distinctions between them especially the last two which, are the key to answering this question. Again, you just cannot memorize a bunch of facts and definitions without putting this information into the context of the disorder/pathology or entity that is presented in the case.

What about those expensive USMLE Prep Courses? What about using review books and memorzing them along with your course work? The problem with most of those expensive review courses is that they present the material by subject and the actual USMLE exams are intergrated. The problem with review books is that they are often superficial summaries of what you already have in your coursework. It is far better for you to organize and thoroughly master your coursework before you attempt a “review”. You cannot “review” what you haven’t thoroughly “learned” in the first place.

Most second-year medical students will take USMLE Step I the summer between second and third year. At my medical school, a passing grade was required on Step I before we could start our clinical rotations in September therefore USMLE Step I had to be taken before the third week in July so that the Dean had received our passing scores. Our coursework was completed at the end of April so that most people took Step I the second or third week of June.Those of us (myself included) who had summer fellowships were required to take our exams before June and thus had to be more efficient. I took Step I the third week in May.

Inevitably, those people who failed the exam, were among the later takers and thus were delayed in starting on the wards. If you took the exam early, you would have time to re-take and start one rotation into your third year but if you waited unti August and then failed, you would drop an entire year of medical school. Bottom line: Take that exam when you are thoroughly prepared and reviewed but don’t wait too late.

How about USMLEWorld and Kaplan’s Q-Bank? These are currently the best question resources available for students. They simulate the actual exam in terms of computer interface and can be used in both the “Test” and “Tutor” mode. The best way to use these resources is to work in 50-question blocks using “All Disciplines” rather than subject by subject. You can use the “Tutor” mode where you can review why the correct answers are correct and the wrong answers are wrong.Beware of feeling confident that if you have a specific percentage correct on USMLEWorld or Q-Bank that you are guaranteed a pass or a specific score. Also beware of memorizing the questions because the questions on the actual exam are different from either of these resources. Both of these on-line question sources have many questions that are more difficult and more specific than USMLE Step I.

These sites are nicely utilized with a study group too. You should do your review and then do a couple of question blocks discussing the answers with each other. You would be surprised how having these types of discussions can enhance your retention and understanding of the material.

Also beware of “one-source” reviews out there. USMLE Step I is an exam that is scheduled for 8-hours over one day. There is no audio “high-yield” review tape or single resource that will give you everything that you need for this exam. You need to practice questions and reveiw systematically.

After you have completed your second year coursework:

  1. Figure out when you are likely to be taking the test. Second or third week of June is generally the most popular dates.
  2. Figure out how you are going to review: Systems-based or subject based.
  3. Gather your resources meaning review books, on-line question systems.
  4. Set a study schedule and stick with it. Don’t make the schedule so tight that you can’t get everything accomplished. Be sure to put in some “down-time” so you can relax as you review.
  5. Use USMLEWorld or Q-Bank as measures of your progress and do not attempt to memorize these questions. For example, if you miss a question, use it again in under test conditons and see if you get it correct. If you miss it a third time, use one of your review books and review the subject matter of that test.
  6. Be wary of subject-based reviews as the actual tests are intergrated. If you do review by subject, be sure to question yourself in an intergrated manner.
  7. Try to have a study group where you can help each other and discuss the questions.

23 March, 2007 - Posted by | choosing a medical school, medical boards, USMLE Step 1


  1. i am medical student from india. i got 203 in step 1. drastically low than what i expected and hoped for. i feel devastated. what are my chances for residency in us?

    Comment by Anonymous | 15 February, 2015 | Reply

    • To Anonymous:
      You should look at the USMLE Step I minimums for IMGs for the specialty programs that interest you. You should apply to programs where you score is above the minimum. You should also try to get some contacts in the United States who can write strong letters of recommendation or make some phone calls. Do be aware that minimum USMLE Step I scores vary by specialty and program with university-based program in medicine and surgery being the most competitive even for American graduates. Also be aware that the number of American medical graduates has significantly increased leaving fewer positions in any specialty for FMG/IMG candidates. Do some solid research, make some strong contacts and choose your specialty carefully to maximize your chances. Good luck.

      Comment by drnjbmd | 15 February, 2015 | Reply

  2. I am 39 year old, having done M.D.(MEDICINE) from India, had 9 years of clinical practice in India, now in USA to appear for USMLE.Can you please tell me whether I can get residency here in USA? Or what else I can do to enter into medical field of USA? Thank you.Awaiting your reply.

    Comment by Naresh | 16 March, 2010 | Reply

    • To Naresh:
      You might want to do a “Google” search for FMGs getting into US residencies. I am not an FMG and I don’t know the routes that you must take to be eligible for residency in the United States. See what you can find online. Good luck

      Comment by drnjbmd | 16 March, 2010 | Reply

  3. Sorry, forgot to mantion i am student in the caribbean…

    Comment by Alex | 19 October, 2009 | Reply

  4. Hi,
    I’like to know what my chances of getting accepted into residency are since I have failed 3 preclinical courses, but got very good score in usmle?


    Comment by Alex | 19 October, 2009 | Reply

    • To Alex:
      Much depends on what you are trying to enter. You may be OK if you are looking at one of the primary care specialties but anything surgical and the ROADs are going to be tough for you. You might have a shot at pathology as long as one of those preclinical failures was not path.

      Apply broadly to a enought programs to get at least 10 solid interviews. It’s tough to match into anything with only a few interviews (even the primary care specialties).

      Comment by drnjbmd | 24 October, 2009 | Reply

  5. My daughter got a 203 on step I exam and is devastated ,that she will not be able to do or study in the field of medicine she chooses. Where can I find more info to ehlp her, is this the end all be all when she has performed at the top of her class for the past two years. Any info would help. I hate to think one test is all there is?

    Comment by JOyce | 12 August, 2009 | Reply

    • To JOyce:
      Your daugther passed Step I and that 203 is her score. In the USMLE Step process, there are no “do-overs”. With that being said, she has her grades from medical school, her performance during year three (clinical performance) in addition to doing a couple of audition rotations in places that she wants to match.

      In addition, I would strongly recommend taking Step II (both parts) as early as possible and doing extremely well on these. Having a strong Step II score in addition to a Step I that is near the mean for US grads can greatly enhance any application. What you and your daughter need to do is focus on the things that are ahead that are totally under her control (her Step II performance and her perfomance clinically during third year). You can’t do anything about that 203 (which is not a deathblow) so focus on what is ahead and what she can work on at this point.

      A 203 is nothing to be devastated about. If she had her heart set on derm, if she doesn’t already have stellar grades in all of her previous coursework, her USMLE score would not have made her competitive for derm at this point. If she has outstanding grades and was at the top of her class, that 203 doesn’t knock her out of the running for derm if she aces Step II and has a very strong third year.

      Good luck.

      Comment by drnjbmd | 13 August, 2009 | Reply

  6. I am currently doing usmle world for step 2 ck. Being an FMG (old grad)I scored an 80% in my step 1 & thus I know how important it is for me to have a good grade in step 2. I have been getting low scores on usmle world around 40% & Im worried about it. Could you please tell me what would be the best way to work around this. I am currently doing wuorld times sujectwise. According to you how do you think it best to do uworld? Also I realise my low scores are due to my poor knowledge base, so should I stop doing Qs & only read kaplans?? How does one improve their knowledge base on the clinical subjects & what would be the best way to study them?

    Comment by bluegirl | 7 June, 2009 | Reply

    • To Bluegirl:
      If your knowledge-base is low, you need more than a question base. You likely need a classroom course. Kaplan has these types of course (along with other companies). The classroom experience would also put you in touch with others with whom you could discuss the material. Questions and answers work well for those who need review but are not optimal for those who need a total refreshment of experiences.

      Comment by drnjbmd | 7 June, 2009 | Reply

  7. Hey Thanks so much for the blog…I really REALLY apreciated it. My husband is a Med Student and he’s UNFORTUNTLY retaking his step 1 because of a past failed atempt…I just wanted a better insite about the test and you really made me understand some things I didn’t realized before.
    From a med students wife: THANK YOU!

    Comment by Med student wife | 10 June, 2008 | Reply

  8. i’m really impressed by your honest and simple approach to this matter that has plagued me.pls send me any more information that you will really be welcomed

    Comment by joyce | 10 July, 2007 | Reply

  9. I just wanted to thank you for the blog. It’s a great service for anyone who is thinking about medicine as a career, and can honestly say it’s permanently altered the way I view the years ahead as I try to get into medicine, but in a positive way. Thanks.

    Comment by Anonymous | 9 April, 2007 | Reply



    Comment by Anonymous | 4 April, 2007 | Reply

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