How to Bend Time for the USMLE Step 1 (Without Threatening the Space-Time Continuum)

  • /Reviewed by: Amy Rontal, MD
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    When it comes to the Step 1, every second matters. Poor timing strategies can wreck even the best student’s test scores. As we fall behind, nervously watching the clock tick away, we begin rushing through questions, making mistakes and gradually lowering our scores.

    If you’ve struggled with timing before on exams, put the following tips to use to practice and optimize your timing strategy so you can crush Step 1.

    Let’s start by talking about the test itself: USMLE Step 1 is composed of 322 multiple-choice items divided into 7 blocks of 46 questions each, with up to 60 minutes allotted for completion of each block. In order to finish each block on time, with no time left over, you must AVERAGE about 1.3 minutes per question (roughly 80 seconds).

    Obviously, finishing with no time to spare is not an ideal test taking strategy as it offers no room for error and provides no additional opportunity to review questions you are unsure of. So how do you finish with time to spare?

    In order to have 5-10 minutes available for review, one must AVERAGE 71-65 seconds per question, respectively.

    Easier said than done, right?

    It may sound intuitive, but learning to effectively and efficiently read and break down a question is a crucial component of exam success. A commonality amongst struggling students is a poor strategy for how they tackle each question stem. Here’s my advice for correcting that:

    1. Read the Actual Question at the End of the Vignette First

    Two reasons for doing this: First, you may often find that the actual question does not require having read the vignette preceding it. A direct question (i.e. what is the mechanism of action of digoxin) would not require you to have read the prior passage, and you would actually be wasting 10-20 seconds having done so.

    Second, even if it’s not a direct question, reading the actual question (and quickly skimming the answer choices) helps put you in the right frame of mind as you process through the details in the question stem. Are you looking for a diagnosis? A medication side effect? An associated symptom?

    Knowing what the question will be asking allows me to process key details as I read them, minimizes the chances of skipping over crucial information, and keeps me from having to go back and read the question a second or third time. Again…every second counts!

    2. Actively Read

    Far too many students simply read the question stem, waiting until the end to start considering what is actually going on. Instead, try processing details and creating a differential diagnosis for the question as you are reading. With each sentence, I ask myself “what is going on?” As I move throughout the rest of the question, I am constantly assessing new information to determine if it supports and strengthens my impression of the question or if it should point me in a new direction.

    3. Highlight Important Details

    As you read through the question, highlight key features of the question: epidemiology, presenting symptoms, pertinent positives and negatives, and crucial physical exam or lab findings. If you do need to read a question stem a second time, having highlighted these key details and drastically shorten the time you spend re-reading.

    4. Selecting Answers

    This is the most important part of each question, and understandably, the part where students tend to lose the most time. For some questions, you’ll read through the answer choices and instantly know the correct answer. For others though, you may struggle.

    Instead of continuing to turn the wheels as precious seconds tick away when you’re stuck, change up your strategy and focus on quickly eliminating incorrect answer choices. Once you’ve eliminated everything that you can, take 20-30 seconds to consider the remaining choices and reason your way to a best guess.

    If you’re strongly considering two answer choices, you can mark the question and come back later if time permits (more on this to come).

    5. Marking Questions

    If you do leave yourself time at the end of a block, you can go back and reevaluate questions that you may have struggled with. Since you won’t have enough time to look at every question, marking is an important feature to help you focus your efforts. However, make sure to use your marks selectively, lest you leave yourself with too many questions to review and a limited opportunity to improve your score.

    Focus on marking questions where you were between two answer choices and additional time could help you confirm your answer or maybe drive you in another direction. Conversely, you should not mark questions that you had no idea what the answer was. Here, it is unlikely that additional time will help you decipher the question, and you’re better off focusing your efforts toward questions where additional time may help you achieve a better score.

    6. Take Breaks

    The USMLEs are marathons, not sprints. Make the most of your break time and keep your energy up. Test fatigue is real and trying to power through too many consecutive sections will only lower your score as you begin to wear down. Once you start a section, there is no pausing; so make sure you are ready to complete that entire block.

    7. Practice Makes Perfect

    Just like Aaron Rodgers and the Packers spend all week practicing plays for their two-minute drill (side note: I’m a huge Packers fan), elite test takers need to practice and perfect their test taking strategy. Fortunately, question banks and NBME examinations provide us with many low-stakes opportunities to fine-tune our skills.

    Make sure that you are using test mode on USMLE World to improve your timing. Don’t sacrifice accuracy for speed. Work to decrease the amount of time you’re spending on each question as you progress through each week of your study schedule. 

    Start applying these timing tricks today and you’ll certainly see your scores rise as you prepare for Step 1. And keep checking back in for more tips and tricks for crushing your USMLE exams.