What is the USMLE Step 1 Exam? (Updated 2025 Guide)
The USMLE Step 1 is the first of three medical licensing examinations required to become a practicing physician in the United States. It assesses whether a medical student understands and can apply the foundational sciences essential to the practice of medicine.
What Content Is Covered on Step 1?
Step 1 focuses on the scientific foundations of clinical medicine. Questions integrate multiple disciplines and require application of concepts rather than simple recall.
Major subjects include:
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Anatomy
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Physiology
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Biochemistry & Molecular Biology
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Pharmacology
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Microbiology
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Pathology
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Immunology
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Genetics
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Behavioral Sciences
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Biostatistics & Epidemiology
These subjects are tested within clinical system categories such as:
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Cardiovascular
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Respiratory
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Renal
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Gastrointestinal
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Endocrine
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Hematology
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Neurology
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Musculoskeletal
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Reproductive
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Psychiatry
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Multisystem processes and disorders
For the most detailed breakdown, refer to the official USMLE Step 1 Content Outline.
Exam Length and Structure
The USMLE Step 1 is an 8-hour exam administered in a single day.
Question Format
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At most, 280 multiple-choice questions
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Divided into 7 blocks
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At most, 40 questions per block
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Each block is 60 minutes
Once time expires, the block automatically submits. If you finish early, the remaining time is added to your break total.
Breaks and Tutorial Time
Break Time
You receive 45 minutes of break time, which you can divide however you prefer between blocks.
Breaks cannot be taken during a block.
Tutorial
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The exam begins with an optional 15-minute tutorial.
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If you skip the tutorial (recommended if you’ve already reviewed it on the NBME website), the unused time is added to your total break time.
Developing an Effective Pace
Most students have never sat for an exam this long. Building endurance is essential.
Suggestions:
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Complete full-length practice tests before your exam.
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Practice taking timed breaks between blocks.
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Some students prefer short, frequent breaks, while others save time for one longer break around the halfway point.
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Skim the answer choices before reading the entire question to reduce unnecessary rereading—especially helpful with long vignettes.
Understanding Step 1 Questions
Step 1 questions use a clinical vignette format. Each item typically includes:
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A patient scenario
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Physical exam findings
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Lab/imaging results
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A question stem
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Five or more answer options
Some questions include multiple steps of reasoning (first-order, second-order, or third-order).
Sample Clinical Vignette
A 22-year-old college student who is confused and lethargic is brought to the emergency department. His roommates report he had a severe headache and neck stiffness last night. Temperature is 104.3°F, blood pressure 80/60 mmHg, heart rate 120 bpm. Physical exam reveals a purpuric rash on the chest. Lumbar puncture shows a high neutrophil count.
What prophylactic treatment should be given to his close contacts?
A. Acyclovir
B. Ceftriaxone
C. Doxycycline
D. Rifampin
E. Vancomycin
Correct Answer: D (Rifampin) – for prophylaxis of Neisseria meningitidis.
Difficulty Level
Questions vary in complexity:
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First-order: direct recall
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Second-order: application
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Third-order: multi-step clinical reasoning
Most Step 1 questions fall into second- or third-order reasoning.
Scoring (Updated)
As of 2022 onward, USMLE Step 1 is officially Pass/Fail.
However, the exam still generates a numerical score internally — it simply is not released.
Residency programs now place increased weight on:
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Step 2 CK
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Clinical grades
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Research
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Letters of recommendation
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Experiences and competencies
Score Release Timeline
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Scores are typically released in 3–4 weeks.
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An email notification is sent when your result is available.
How to Register for Step 1 (Updated Process)
The registration process can take 2–4 weeks, so begin early.
1. Create an NBME/USMLE Account
You will receive a USMLE ID via email.
2. Submit the Step 1 Application
You will complete your application online and pay the current exam fee ($670 as of 2025; subject to change).
3. Verify Enrollment With Your Medical School
You will receive a certification form to print, sign, and attach a photo.
4. Obtain School Verification
Your school must confirm your enrollment and send the form to NBME.
5. Receive Your Scheduling Permit
Once approved, you will get your permit by email.
Scheduling Your Exam
All scheduling is done through Prometric.
Available testing dates generally open 6 months in advance.
Fees (Updated for 2025)
Registration Fee
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$670 (U.S. and Canada test centers; updated from $645)
Rescheduling Fee
Depends on how close you are to the exam date:
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31+ days: $0
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6–30 days: approx. $50
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5 days or fewer: approx. $125
(Exact fees vary annually; check USMLE.org for updates.)
Final Tips for Step 1 Success
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Start using NBME practice exams early to gauge progress.
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Build stamina for the full 8-hour testing day.
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Review the Prometric testing environment ahead of time.
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Treat every practice test like the real thing.
