Exam Prep
Preparing for Step 1
by Mike
Apr 11, 2026 · 10 min read
Exam Prep
by Mike
Apr 11, 2026 · 10 min read
Step 1 has been pass/fail since January 2022, and the passing score is 196. It no longer puts a three-digit number on your residency application, but you still have to pass it to move on. What you learn for it also carries straight into rotations, shelves, Step 2 CK, and Step 3.
Step 1 is one day, one 8-hour session. Starting May 14, 2026, it uses a new format: 14 blocks of up to 20 questions, 30 minutes each. The total number of questions (up to 280) and the total time didn't change. You get 55 minutes of break time, and finishing a block early adds the leftover time to your break pool (it isn't a contest to see who finishes with the most extra time, though). The new software also has better keyboard navigation and image contrast tools.
Practice in the new block length. Set your question banks to timed 20-question, 30-minute blocks. Shorter blocks mean less time to settle in and twice as many transitions over the day (14 instead of 7). Plan your breaks ahead of time.
Content is organized by organ system and discipline. The foundational sciences are anatomy, biochemistry, physiology, microbiology, immunology, pharmacology, pathology, genetics, and behavioral science with biostatistics. The organ systems are cardiovascular, respiratory, renal, GI, reproductive, endocrine, musculoskeletal, heme/onc, neurology, psychiatry, dermatology, and multisystem/general principles.
The exam loves integration. One question will often ask you to connect the pathophysiology of a disease, what it looks like clinically, the pharmacology of the treatment, and the relevant anatomy.
If you've been doing Anki, Pathoma, Sketchy, and a question bank all through M1 and M2, a big part of your Step 1 prep is already done. Dedicated is for shoring up, filling gaps, and building stamina. The preclinical study guide covers that stretch.
Most people take 4 to 8 weeks. The right length depends on what you already know, your practice scores, and how ready you feel. People who kept up with board resources through preclinical usually need less.
Before dedicated starts, try to have:
First Aid is your map during dedicated. It's an index of what's testable, not something you learn from on its own. Use it to find gaps, organize your review, and collect notes from questions and other resources.
UWorld is the most important resource in dedicated. The questions are well written, the explanations are thorough, and doing them teaches you how Step 1 questions are built.
I liked tutor mode, untimed, with random or system-based blocks. Use system-based blocks early on if you're working on a specific weakness.
Review every question, including the ones you got right. The explanations often teach more than the question itself.
Track your performance by subject so you know where you're weak.
Don't memorize questions. Learn the concept well enough to handle it when it's worded differently.
For pacing, with 6 weeks of dedicated, aim for 3 to 6 blocks of 20 a day (60 to 120 questions). Full disclosure, I did about 200 a day because I took a short dedicated. Do some timed 20-question, 30-minute blocks to match the real thing. That still leaves time for review and Anki. Adjust for your energy.
Use Pathoma to patch weak spots that come up in UWorld or First Aid. I didn't rewatch it during dedicated because I already knew the content well by then, and Anki handled the review. Dr. Sattar is goated.
If you used Sketchy in preclinical, keep doing the Anki cards (briefly, since just seeing the picture is often enough). If you never used it, dedicated is late to start from scratch, but the micro and pharm sections can still help if those are big gaps for you.
A good resource, but grinding through it in dedicated usually isn't the best use of time since it's passive. It's useful for topics First Aid doesn't explain well enough, and the physiology-heavy systems (cardio, renal, pulm, endocrine) are covered well. Pick the videos you need instead of rewatching the series.
Keep up your daily reviews. If they get huge (300+ a day), cut new cards and focus on keeping what you have. If you're comfortably passing practice exams and doing well on UWorld, it's fine to stop reviews during dedicated.
Practice exams tell you whether you're ready, build stamina, and show you where you're weak.
The NBME self-assessments (CBSSA forms) predict the real exam best. Plan on 2 to 5 during dedicated, about 1 to 2 weeks apart. I only took one, got a 91%, and stopped there.
Take one or two in the middle weeks to see where you are, and one about a week before the exam as a final check. To save money, you can use the UWorld self-assessments instead for some of these.
Passing several NBMEs with room to spare should give you confidence. If you're scoring below passing, think about pushing the exam back and working on specific weak areas. Feel free to reach out or leave a comment on my YouTube videos with questions.
The Free 120 on the USMLE website is free and uses the same interface as the real exam. Take it in the last week so the software feels familiar. For me it was the most predictive of all.
UWorld has two (UWSA1 and UWSA2). They're useful extra data, but most people find them less predictive than NBME forms.
Use them to find weak subjects. The number itself matters less. After each one, go through every miss and sort it: did you not know it, misread it, or reason your way to the wrong answer? That tells you where to spend the time you have left.
A typical day might look like this:
This is a template, not a rule. Some people do better with questions in the morning and review in the afternoon, and some the other way around.
After the first week or two, UWorld and your first practice exam will show you your weak areas. Move your time toward them. If you keep missing renal physiology, watch the Boards and Beyond renal videos, reread the First Aid renal section, and do Amboss questions filtered to renal.
Don't split time evenly across subjects. Put extra time into weaknesses and keep your strengths up with mixed blocks.
Get a full night's sleep. Don't cram the night before. Eat a real breakfast and bring snacks and caffeine for breaks. Get to the testing center early so you aren't starting the day stressed about parking.
With 14 blocks, decide your break plan ahead of time. You don't need a break after every block. A lot of people do two or three blocks, then break. Eat, drink, and reset.
Let each block go when it's over. Replaying old questions takes energy away from the block in front of you.
Flag the ones you're unsure of and come back at the end of the block if there's time. Change an answer when you find something you missed.
Pace yourself. You have about 90 seconds a question, and with 20-question blocks there's less room to make up time. If one is dragging, pick your best answer, flag it, and move on.
Feeling unsure or anxious afterward is normal, and lots of people walk out sure they failed. I did too, even though it was very unlikely. The exam writers are very good at making you feel that way.
Some topics show up heavily and reliably. Make sure you're comfortable with these.
Pathoma chapters 1 to 3 (cell injury, inflammation, and neoplasia) come up in questions across every organ system.
Biostatistics and epidemiology, including sensitivity, specificity, PPV, NPV, odds ratio, relative risk, NNT, study designs, and biases, are free points if you review them. We have a YouTube playlist for it.
For pharmacology, know mechanisms, side effects, interactions, and toxicities for the major drug classes. Sketchy Pharm covers it well.
For microbiology, know the organisms, virulence factors, treatments, and resistance patterns. Sketchy Micro with Anki is the fastest way in.
Biochemistry means enzyme deficiencies, metabolic pathways, lysosomal and glycogen storage diseases, and amino acid derivatives. It gets tested a lot and mostly takes memorization (Dirty Medicine has good memory hooks).
For embryology, know the high-yield developmental defects and their associations, like neural crest and branchial arch derivatives and heart defects.
Anatomy is targeted: nerve injuries, the brachial plexus, dermatomes, and the blood supply to specific regions. You need the high-yield associations, not all of anatomy.
Ethics and patient safety cover autonomy, beneficence, non-maleficence, justice, informed consent, capacity, confidentiality, and mandatory reporting. These are usually straightforward if you've reviewed them.
Starting UWorld with no foundation. UWorld works best when you have something to build on. Doing it before you've seen the material mostly just demoralizes you.
Skipping practice exams. NBMEs are the best read on whether you're ready. Without them you're guessing.
Letting yourself go in dedicated. It's a sprint, but six weeks still needs sleep, exercise, and breaks. Burning out in week three of six will cost you.
Switching plans halfway. Unless someone you trust tells you to change course, pick a plan and stick with it. Swapping resources every few days leaves holes and wastes time.
Step 1 is pass/fail. The goal is to pass comfortably and keep what you learned. The people who do that best studied steadily in preclinical, used a small set of resources, and went into dedicated with a plan.
If you've done the checklist and you're passing practice exams with room to spare, you're ready.
Best of luck!
Mike
Disclaimer: StrudelMed / Strudel Academy LLC is an independent medical education resource. The content above 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.