USMLE Step 1

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The USMLE Step 1 (more commonly just Step 1 or colloquially, The Boards) is the first part of the United States Medical Licensing Examination. It assesses whether medical school students or graduates can apply important concepts of the foundational sciences fundamental to the practice of medicine. US medical students, as well as non-US medical students who wish to seek licensure to practice medicine in the US, typically take Step 1 at the end of the second year of medical school. Graduates of international medical schools (i.e., those outside the US or Canada) must also take Step 1 if they want to practice in the US. Graduates from international medical schools must apply through ECFMG, and the registration fee is $850.[1] For 2016, the NBME registration fee for the test is $600, with additional charges for applicants who choose a testing region outside the United States or Canada.[2]


Prior to 1992, the NBME Part I examination served as the staple basic science examination for medical students at the end of their second year. Upon the launch of the three-part United States Medical Licensing Examination, NBME Part I exam was carried forward in its new format, the USMLE Step 1 examination, which has since evolved to become an increasingly clinically-applied examination of the foundational sciences. The exam became computer based several years later. In May 2015, the USMLE began emphasizing of concepts regarding patient safety and quality improvement across all parts of the USMLE exam series, including Step 1.[3]

In recent years and in part resulting from the American Medical Association's "Accelerating Change in Education" (ACE) Initiative, a number of U.S. allopathic and osteopathic medical schools have begun to consolidate the amount of time allocated in the 4-year curriculum for dedicated preclinical/classroom-based education in order to provide more time for clinical training and direct application of the foundational sciences to clinical medicine. As a result of this paradigm shift away from the 20th century "2+2" curriculum, students at many of these medical schools are now instructed to take the Step 1 exam following the core clerkship year, rather than at the conclusion of the preclinical curriculum, at which time students are also prepared to sit for the Step 2 CK exam. The effect of this variable timing for students sitting for the Step 1 exam is presently unknown.


The exam is currently an eight-hour computer-based test taken in a single-day, composed of seven 40-question sections with a maximum 280 multiple-choice questions.[4] On May 9, 2016, the NBME shortened the test to seven 40-question sections.[5] One hour is provided for each section, allotting an average of a minute and thirty seconds to answer each question.[6] Between test sections, the test taker is allotted a cumulative 45 minutes (during the test day) for personal breaks. (There is a 15-minute tutorial at the beginning of the exam, which the test-taker can choose to skip and have that time added to break time.) If the taker finishes any section before the allotted one hour time limit, the unused time is added to the break time total.[7] The test is administered at any of several Prometric computer testing sites.


Step 1 is designed to test the knowledge learned during the basic science years of medical school as applied in the form of clinical vignettes. This includes anatomy, behavioral sciences, biochemistry, microbiology, pathology, pharmacology, and physiology, as well as to interdisciplinary areas including genetics, aging, immunology, nutrition, and molecular and cell biology.[8] Epidemiology, medical ethics and questions on empathy are also emphasized. Each exam is dynamically generated for each test taker; while the general proportion of questions derived from a particular subject is the same, some test takers report that certain subjects are either emphasized or deemphasized.


Currently, students receive a three-digit score following sitting for the Step 1 examination. In 1999, the USMLE phased out the use of a percentile-based system in favor of a three-digit and two-digit scaled scoring system. In October 2011, two-digit scaled scores were no longer reported to any parties besides the examinees. In April 2013, the two-digit score was eliminated completely from the score report.

While the USMLE program does not disclose how the three-digit score is calculated, Step 1 scores theoretically range from 1 to 300, most examinees score in the range of 140 to 260, the passing score is 192, and the national mean and standard deviation are approximately 229 and 20, respectively.[9][10] Inflation in the national mean Step 1 score has been observed with time, as shown in the table below.[11] According to the National Resident Matching Program, the mean score for U.S. allopathic seniors who matched to residency programs in 2016 was 233.2 (sd = 17.4).[12]

National Step 1 means among US and Canadian first time test-takers by year
Year Mean Score Standard Deviation
2016 228 21
2015 229 20
2014 229 20
2013 228 21
2012 225 21
2011 225 22
2010 222 24
2009 221 24
2008 221 23

Effect on residency matching[edit]

The USMLE score is one of many factors considered by residency programs in selecting applicants. However, at present, this test is the only standardized measure of all applicants. The median USMLE Step 1 scores for graduates of U.S. Medical Schools for various residencies are charted in Chart 6 on page 9 of "Charting Outcomes in the Match" available through NRMP Website

Many residency programs use a "cutoff" score for Step 1, below which applicants are unlikely to be considered, although in some cases individuals with significantly higher Step 2 CK scores may still receive further consideration. The NRMP Residency Program Director survey contains more information, both overall and by specialty, regarding "cutoff" scores (i.e., scores below which programs generally do not grant interviews).[13]

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