Exam Prep
Step 1 Preparation Guide
Apr 11, 202612 min read
By Mike
By MikeDisclaimer: StrudelMed / Strudel Academy LLC is an independent medical education resource. The content below is not medical or clinical advice and is intended for educational purposes and general guidance only. Exam format, scoring, and content may change. Always check the USMLE website for the most current information.
Step 1 is a one-day exam administered in an 8-hour testing session. Starting May 14, 2026, the exam will use an updated format: 14 blocks of up to 20 questions each, with 30 minutes per block. The total number of questions (up to 280) and total exam duration are unchanged from the previous format. You have a of 55 minutes of break time, and finishing blocks early adds unused time to your break pool (it is not a competition to see who finishes with the most extra time though). The updated testing software also includes an improved interface with better keyboard navigation and image contrast adjustment tools.
Practice with the new block length. Set your question banks to 20-question, 30-minute timed blocks to match the current exam format. The shorter blocks mean less time to warm up within each block and more transitions throughout the day (14 vs the previous 7). Plan your break strategy in advance.
Content is organized by organ system and discipline. The major disciplines tested include:
Foundational sciences: Anatomy, biochemistry, physiology, microbiology, immunology, pharmacology, pathology, genetics, and behavioral sciences/biostatistics.
Organ systems: Cardiovascular, respiratory, renal, gastrointestinal, reproductive, endocrine, musculoskeletal, hematology/oncology, neurology, psychiatry, dermatology, and multisystem/general principles.
The exam emphasizes integration. Questions frequently require you to connect multiple disciplines (e.g., understanding the pathophysiology of a disease, recognizing it clinically, knowing the pharmacology of its treatment, and understanding the relevant anatomy).
If you have been using Anki, Pathoma, Sketchy, and a question bank throughout preclinical years, you have already done a significant portion of your Step 1 preparation. Dedicated will be focused on reinforcing, filling gaps, and building test-taking endurance.
Most students take 4 to 8 weeks of dedicated study time. The right length depends on your baseline knowledge, practice exam scores, and comfort level. Students who have been consistent with board resources throughout preclinical years often need less dedicated time.
Before dedicated begins:
First Aid is your roadmap during dedicated. It is not a learning tool on its own but a comprehensive index of testable content. Use it to identify gaps, organize your review, and annotate with notes from questions and other resources.
UWorld is the single most important resource during dedicated. The questions are well-written, the explanations are thorough, and working through them teaches you how Step 1 questions are constructed.
How to use UWorld:
Pacing: If you have 6 weeks of dedicated, aim for 3 to 6 blocks of 20 questions per day (60 to 120 questions). Full disclosure, I used to do 200 questions a day since I took a short dedicated. You can also set your question bank to 20-question timed blocks (30 minutes) to match the current exam format. This leaves time for thorough review and Anki. Adjust based on your schedule and energy.
For organ system pathology, use Pathoma as a supplement when you encounter weak areas in UWorld or First Aid. I didn't actually watch Pathoma chapters again during dedicated but had a good grasp of the content by the time I started dedicated, but Anki is great for review. Dr. Sattar is goated.
If you used Sketchy during preclinical years, continue reviewing the associated Anki cards (briefly, just seeing the pictures is often enough) to maintain retention. If you did not use Sketchy, dedicated is late to start from scratch, but the microbiology and pharmacology sections can still be valuable if you have significant gaps in those areas.
Good resource overall, probably not the best use of time to grind during dedicated since its passive learning. Useful during dedicated for topics you find difficult to understand from First Aid alone. Physiology-heavy topics (cardio, renal, pulmonary, endocrine) are well-covered. Use it selectively if you do rather than watching the entire series again.
Continue daily reviews throughout dedicated. If your review load is very high (300+ cards per day), consider reducing new cards and focusing on retention of existing material. You can stop reviews during dedicated if you are comfortably passing on your practice exams and scoring well on UWorld.
Practice exams are essential for gauging readiness, building stamina, and identifying weak areas.
NBME (CBSSA) forms are the best predictors of your actual Step 1 performance. Take 2 to 5 forms during dedicated, spaced approximately 1 to 2 weeks apart. I only ended up taking one NBME form and scored a 91% so I didn't take any more.
Suggested schedule:
A passing score on multiple NBMEs with a comfortable margin provides confidence going into exam day. If you are scoring below passing on practice exams, consider extending your dedicated period and addressing specific weak areas. Feel free to reach out or leave comments on my YouTube videos with questions.
The USMLE Free 120 (available on the USMLE website) is a free practice exam that uses the same interface as the real exam. Take it in the last week of dedicated to familiarize yourself with the testing software and question style. I found this to be most predictive for the real exam.
UWorld offers two self-assessments (UWSA1 and UWSA2). These are useful additional data points but are generally considered less predictive than NBME forms.
Use practice exams to identify weak subjects, not just to generate a number. After each practice exam, review every incorrect question and categorize your mistakes: was it a knowledge gap, a misread of the question, or a reasoning error? This tells you where to focus your remaining study time.
A typical dedicated study day:
Morning: Three to four blocks of UWorld (60 to 80 questions, timed, random, 20 questions per block).
Midday: Review UWorld questions from the morning. Annotate First Aid (optional).
Afternoon: Two additional blocks of UWorld (40 questions). Continue review. Read First Aid sections corresponding to weak areas.
Evening: Light review. Skim First Aid rapid review or do a quick pass through Anki. Do not study late into the night (unless you want to).
This is a template, not a mandate. Adjust based on your energy, learning style, and schedule. Some students do better with questions in the morning and review in the afternoon. Others prefer the reverse.
After the first 1 to 2 weeks of dedicated, you should have a clear picture of your weak areas from UWorld performance and practice exams. Shift your study time toward these areas. If you are consistently missing renal physiology questions, spend extra time on Boards and Beyond renal, re-read the First Aid renal section, and do Amboss questions filtered to renal.
Do not spend equal time on every subject. Double down on weaknesses while maintaining your strengths through mixed question blocks.
Before the exam:
During the exam:
After the exam:
Certain topics are tested heavily and reliably on Step 1. Make sure you are comfortable with:
Pathoma chapters 1 to 3: Cell injury, inflammation, and neoplasia. These concepts underpin questions across every organ system.
Biostatistics and epidemiology: Sensitivity, specificity, PPV, NPV, odds ratio, relative risk, NNT, study designs, and biases. These are free points if you review them, you can check out our YouTube playlist (https://youtube.com/playlist?list=PLrmR4fmwLiGxjAfhRGu8mRt6ya0Ft5upv&si=czs9c_K1wNlUkpub).
Pharmacology: Mechanisms of action, side effects, drug interactions, and toxicities for major drug classes. Sketchy Pharm covers this effectively.
Microbiology: Organisms, virulence factors, treatments, and resistance patterns. Sketchy Micro x Anki is the most efficient way to learn this.
Biochemistry: Enzyme deficiencies, metabolic pathways, lysosomal storage diseases, glycogen storage diseases, amino acid derivatives. These are frequently tested and often require memorization (Dirty Medicine has good memory hooks).
Embryology: High-yield developmental defects and their associations (e.g., neural crest derivatives, branchial arch derivatives, heart defects).
Anatomy: Targeted anatomy questions (nerve injuries, brachial plexus, dermatomes, blood supply to specific regions). Not comprehensive anatomy but specific high-yield associations.
Ethics and patient safety: Autonomy, beneficence, non-maleficence, justice, informed consent, decision-making capacity, confidentiality, mandatory reporting. These are testable and often straightforward if you have reviewed them.
Starting UWorld too early without a foundation. UWorld is most effective when you have baseline knowledge to build on. Doing it before you have covered the material leads to poor performance that is demoralizing rather than educational.
Ignoring practice exams. NBMEs are the most reliable way to assess readiness. Students who skip practice exams are making decisions without data.
Neglecting wellness during dedicated. Dedicated is a sprint, but a 6-week sprint still requires sleep, exercise, and breaks. Students who burn out in week 3 of a 6-week plan underperform.
Changing study plans mid-dedicated. Unless advised individually by a trusted advisor, stick a plan and stick with it. Switching resources or strategies every few days leads to incomplete coverage and wasted time.
Step 1 is pass/fail. Your goal is to pass with confidence and carry the knowledge forward. The students who do this most effectively are those who study consistently during preclinical years, use a focused set of resources, and approach dedicated with a clear plan.
If you have completed the checklist above and are scoring comfortably above passing on practice exams, you are ready. Trust your preparation.
Best of luck!
— Mike