What to Expect from the USMLE Step 1, Tips from a Question Bank Author

  • /Reviewed by: Amy Rontal, MD
  • Derek Kong, Yale medical student and PasTest contributor, explains in what ways Step 1 questions are different from questions on undergraduate exams.

    By the time you get to medical school, you may already think of yourself as a professional test taker. However, the USMLE Step 1 promises to be a completely different animal than undergraduate exams. Derek Kong, Yale medical student and PasTest contributor, explains why. “On a chemistry test, for example, you may have been asked ‘What reagents should you use to make this molecule?’ or ‘What are the steps of this reaction?”, he says. “Undergraduate exam questions are often very direct and explicit.” Below, Derek mentions three clear examples of what makes Step questions different.

    Questions with multiple steps

    Step 1 questions, by contrast, require two or three steps, meaning that you will need to correctly make multiple inferences to get to the answer. Questions on Step 1 begin with patient presentations. “Typically, they give you some combination of vitals, physical exam findings, lab values, and imaging,” says Derek. “A Step 1 question won’t tell you that the patient has AIDS or that the patient has pneumonia. Instead, they will tell you that the patient has a low CD4 count, and it is up to you to make the inference to AIDS. A patient with productive cough, fever, and dullness to percussion on lung exam might have pneumonia.”

    You are asked to select the best choice

    On Step 1, you will often be asked to choose the best answer choice. “Take the case of pneumonia,” Derek says, “The question won’t tell you whether the pneumonia is hospital-acquired or community-acquired. Making this inference will help you decide what drug is best to prescribe. You may also know that the patient is allergic to a certain drug class. In this scenario, the best answer wouldn’t be necessarily the first-line medication, but a second- or third-line that’s appropriate for that patient.”

    Timing is a bigger factor

    “Mapping a question is a technique that people have used in the past for the verbal sections of the MCAT. However, there’s not a lot of time to do that on Step 1. It turns out to be slightly more than a minute per question,” says Derek. With timing being a concern, it is best to have a plan for how you will tackle questions that throw you off. “For me, if I do not understand what the question is getting at in the first ten seconds of the question, I’m just going to mark it, skip it, and come back to it. You don’t want to get bogged down by one question where you spend two or three minutes and then miss easy questions that you can nail later on.”