USMLE Step 1
NBME/FSMB
Complete guide to passing the USMLE Step 1 exam on your first attempt.
$665
~93% (now Pass/Fail)
7 years for licensing
USA
NBME/FSMB
Medical residency matching
Are you ready for USMLE Step 1?
Loading quiz...
Complete Overview
USMLE Step 1 is the first of the three examinations required for medical licensure in the United States, and it tests whether a candidate can apply basic science concepts to the practice of medicine. It is taken by students and graduates of LCME-accredited MD programs, COCA-accredited DO programs, and medical schools outside the United States that are listed in the World Directory of Medical Schools as meeting ECFMG eligibility requirements; the 2026 and 2027 application fee is 695 dollars, plus a 210 dollar region fee for anyone testing outside the United States and Canada. Since 26 January 2022 the result has been reported as pass or fail only, with no three-digit score released. The exam runs for one 8-hour session at a Prometric test centre. Two delivery formats exist in 2026: exams taken before 14 May 2026 use seven 60-minute blocks of up to 40 items, and exams taken on or after 14 May 2026 use fourteen 30-minute blocks of up to 20 items. The USMLE program confirmed that the content, the 280-item maximum and the 8-hour day did not change with the software update; only the block structure and the interface did. The newer software adds a settings menu, per-image contrast adjustment and improved keyboard navigation. Break time also shifted: the older format allotted a minimum of 45 minutes of break plus a 15-minute optional tutorial, while the newer one allots a minimum of 55 minutes of break plus a 5-minute optional tutorial. Every item is a single-best-answer multiple choice question built around a patient vignette, with four or more lettered options. USMLE states that unanswered questions are automatically counted as wrong, so guessing is always better than leaving a blank. Content is organised by organ system rather than by classical discipline: the published system specification runs from 12 to 16 per cent for reproductive and endocrine systems down to 1 to 3 per cent for human development, and USMLE publishes ranges rather than fixed percentages because coverage varies from form to form. Discipline coverage overlaps deliberately, which is why USMLE's own discipline table totals more than 100 per cent, with pathology classified at 45 to 55 per cent of items and physiology at 30 to 40 per cent. The passing standard is fixed in advance rather than curved. USMLE reports that examinees typically must answer about 60 per cent of items correctly to pass, and that on the retired three-digit scale the Step 1 passing standard is 196. Pass rates published by USMLE for 2025 show 93 per cent of first-time takers from US MD-granting schools passing, 89 per cent from DO-granting schools, and 75 per cent of first-time takers from non-US schools. Repeaters do far worse: 71 per cent for US MD repeaters and 54 per cent for non-US repeaters. Four failed or incomplete attempts at any single Step make a candidate permanently ineligible for the entire USMLE sequence, which is the single hardest constraint in the whole process and the reason candidates should not sit the exam before their practice test scores are stable.
Why Get USMLE Step 1 Certified?
Step 1 is one of three exams that every physician licensed in the United States must pass, and most state boards require all three Steps within a seven-year window that starts when you pass your first Step.
Passing Step 1 and Step 2 CK is the medical science examination requirement for ECFMG Certification, which international medical graduates must hold before entering an ACGME-accredited residency programme.
USMLE reported that 29,870 examinees from US MD and DO schools and 25,660 from non-US schools sat Step 1 in 2025, so the cohort you are compared against is roughly 55,000 people a year.
The attempt limit is absolute: four attempts at a single Step, incompletes included, ends eligibility for every Step in the sequence, so a first-attempt pass protects the entire career path.
Failing costs a full 695 dollar application fee again, plus the 210 dollar region fee for international test centres, plus a Prometric change fee of up to 158 dollars if you move the appointment within five days.
Step 1 is a prerequisite for Step 3, which in turn is required for unrestricted licensure; USMLE reports the Step 3 pass rate for 2025 at 96 per cent for US school graduates and 85 per cent overall for non-US graduates.
Prometric delivers Step 1 at roughly 335 US and Canadian test centres and about 100 international centres, so candidates can test close to home almost year-round rather than waiting for a fixed sitting.
Exam Format & Structure
Duration
420 minutes of testing time inside one 8-hour session. Exams on or after 14 May 2026 use fourteen 30-minute blocks; exams before that date used seven 60-minute blocks. The 8-hour day also contains a minimum of 55 minutes of break time and a 5-minute optional tutorial in the newer format, or 45 minutes of break and a 15-minute tutorial in the older one. Finishing a block or the tutorial early adds the unused minutes to your break bank.
Questions
280 multiple-choice items maximum. In the format used from 14 May 2026, that is up to 20 items in each of fourteen blocks; in the earlier format it was up to 40 items in each of seven blocks.
Passing Score
Pass or fail only for all exams administered on or after 26 January 2022. USMLE states that on the three-digit scale the Step 1 passing standard is 196, and that examinees typically must answer approximately 60 per cent of items correctly to pass. No three-digit score is released to the examinee or to programmes.
Question Types
- Single-best-answer multiple choice built on a patient-centred vignette, with four or more lettered options and exactly one best answer
- Items requiring interpretation of graphic and tabular material, including lab panels and physiological tracings
- Items requiring identification of gross specimens, microscopic pathology slides and normal histology
- Items with associated audio findings, such as heart and lung sounds, which is why the headphone sound check must be run before or during the tutorial
- Biostatistics and epidemiology items on study design, research ethics and regulatory issues
- Communication items that ask for the most appropriate initial statement by a physician
Delivery Method
Computer-based at Prometric test centres, with biometric check-in. Step 1 is administered worldwide, unlike Step 3, which is offered only in the United States and its territories. There is no online-proctored, at-home option.
How scoring works
Score scale
Pass or fail only, for every exam administered on or after 26 January 2022. USMLE results were historically reported on a three-digit scale and Step 2 CK and Step 3 still are, at minimum passing scores of 218 and 200 respectively, but Step 1 examinees receive no number.
Score needed to pass
USMLE states that on the three-digit scale the Step 1 passing standard is 196, and that examinees typically must answer approximately 60 per cent of items correctly to achieve a passing score. USMLE has said that future reviews of the Step 1 passing standard will not be reported in terms of a three-digit score.
Roughly what that means raw
USMLE publishes no raw-to-scale conversion table for Step 1. The only raw figure it gives is that examinees typically must answer approximately 60 per cent of items correctly to pass, and it states that this percentage varies by Step and from form to form.
When results arrive
There is no unofficial result at the test centre. USMLE's results page says results are typically available within four weeks of the test date and the Bulletin of Information says two to four weeks; both add that various factors can delay reporting and that you should allow at least eight weeks when choosing a test date. Scores are processed continuously and reported weekly. You get an email from your registration entity, NBME for US students and graduates or FSMB for international medical graduates, and the score report stays on that entity's site for about 365 days before you must pay for a transcript instead.
How the scale is built
The standard is criterion-referenced, not curved: USMLE states that no predetermined percentage of examinees will pass or fail, because passing depends on reaching a fixed proficiency level. Statistical equating keeps that level constant across different forms, which is why the percentage of items you must answer correctly varies from form to form. Scoring is compensatory across systems; there is no per-domain minimum. Wrong answers carry no extra penalty, and unanswered items are scored as wrong.
Pacing and time budget
280 questions in 420 minutes gives you 1 minute 30 seconds per question.
15 (halfway through any 30-minute block)
10 of that block's 20 items
22 (three-quarters through any block)
15 of that block's 20 items, leaving 8 minutes for the last 5 and for review
120 (four blocks of testing time elapsed)
80 of 280
210 (seven blocks, the halfway point of testing time)
140 of 280
360 (twelve blocks)
240 of 280, with two blocks left
| At this point | You should have answered |
|---|---|
| 15 (halfway through any 30-minute block) | 10 of that block's 20 items |
| 22 (three-quarters through any block) | 15 of that block's 20 items, leaving 8 minutes for the last 5 and for review |
| 120 (four blocks of testing time elapsed) | 80 of 280 |
| 210 (seven blocks, the halfway point of testing time) | 140 of 280 |
| 360 (twelve blocks) | 240 of 280, with two blocks left |
- Ninety seconds per item is the whole budget, and long haemodynamic-table items eat two or three times that. Bank time on the short recall items so the table items do not force you to rush the block's last five questions.
- The 30-minute block is a hard boundary. You can review only within the current block, and once it closes you cannot go back, so a flagged item left unanswered at the 29-minute mark is a lost point rather than a deferred one.
- Finishing a block early is not wasted effort. Unused block minutes are added to your break bank, which is the only way to extend the minimum 55 minutes of break in the current format.
- Answer every item even when you are out of time. USMLE counts unanswered questions as wrong, and there is no deduction for a wrong guess, so the last 30 seconds of every block should be spent filling blanks.
- Use the time summary feature described in the tutorial to watch both the block clock and the day clock. Exceeding your accumulated break time is deducted from testing time, which is the one way a break decision can cost you scored minutes.
Where the marks are
Reproductive and endocrine systems
12 to 16 per cent
The largest published system band. Expect feedback-axis reasoning: given a hormone panel, decide whether the lesion is primary, secondary or tertiary, and which enzyme or receptor is at fault.
Respiratory and renal or urinary systems
11 to 15 per cent
Acid-base compensation, nephron transport and diuretic sites, and ventilation-perfusion reasoning. Questions give you an arterial blood gas or an electrolyte panel and ask for the mechanism, not the label.
Behavioural health and nervous systems, special senses
10 to 14 per cent
Lesion localisation from a deficit pattern, plus receptor-level pharmacology. Cranial nerve and spinal tract questions reward anatomy that can be drawn rather than recited.
Biostatistics, epidemiology and social sciences
10 to 15 per cent combined (published as 4 to 6 and 6 to 9)
Study design identification, two-by-two table calculations, research ethics, and communication items asking for the most appropriate initial statement by the physician. Learnable in days and rarely missed once drilled.
Blood and lymphoreticular or immune systems
9 to 13 per cent
Anaemia workup by mean corpuscular volume, coagulation panel interpretation, hypersensitivity types, and immunodeficiencies identified through the infections they permit.
Musculoskeletal system, skin and subcutaneous tissue
8 to 12 per cent
Autoantibody patterns, crystal findings, collagen and bone remodelling defects, and skin histology. Heavy on image interpretation of gross and microscopic specimens.
Multisystem processes and disorders
8 to 12 per cent
Genetics, nutrition, neoplasia principles and shock physiology. This is where pedigree analysis, trinucleotide repeats, vitamin deficiencies and paraneoplastic syndromes live.
Cardiovascular system
7 to 11 per cent
Pressure-volume loops, murmur manoeuvres and the haemodynamic table format USMLE uses in its own published sample item, where the answer is a row of directional arrows.
| Topic | Weight | Why it scores |
|---|---|---|
| Reproductive and endocrine systems | 12 to 16 per cent | The largest published system band. Expect feedback-axis reasoning: given a hormone panel, decide whether the lesion is primary, secondary or tertiary, and which enzyme or receptor is at fault. |
| Respiratory and renal or urinary systems | 11 to 15 per cent | Acid-base compensation, nephron transport and diuretic sites, and ventilation-perfusion reasoning. Questions give you an arterial blood gas or an electrolyte panel and ask for the mechanism, not the label. |
| Behavioural health and nervous systems, special senses | 10 to 14 per cent | Lesion localisation from a deficit pattern, plus receptor-level pharmacology. Cranial nerve and spinal tract questions reward anatomy that can be drawn rather than recited. |
| Biostatistics, epidemiology and social sciences | 10 to 15 per cent combined (published as 4 to 6 and 6 to 9) | Study design identification, two-by-two table calculations, research ethics, and communication items asking for the most appropriate initial statement by the physician. Learnable in days and rarely missed once drilled. |
| Blood and lymphoreticular or immune systems | 9 to 13 per cent | Anaemia workup by mean corpuscular volume, coagulation panel interpretation, hypersensitivity types, and immunodeficiencies identified through the infections they permit. |
| Musculoskeletal system, skin and subcutaneous tissue | 8 to 12 per cent | Autoantibody patterns, crystal findings, collagen and bone remodelling defects, and skin histology. Heavy on image interpretation of gross and microscopic specimens. |
| Multisystem processes and disorders | 8 to 12 per cent | Genetics, nutrition, neoplasia principles and shock physiology. This is where pedigree analysis, trinucleotide repeats, vitamin deficiencies and paraneoplastic syndromes live. |
| Cardiovascular system | 7 to 11 per cent | Pressure-volume loops, murmur manoeuvres and the haemodynamic table format USMLE uses in its own published sample item, where the answer is a row of directional arrows. |
The numbers
93 per cent, from 23,028 first-time examinees. Repeaters from the same schools passed at 71 per cent.
First-time pass rate, US MD-granting schools, 2025
Source: USMLE Performance Data, Step 1 administrations (usmle.org/performance-data)
75 per cent, from 22,066 first-time examinees. Repeaters passed at 54 per cent, and the combined non-US total was 72 per cent of 25,660 examinees.
First-time pass rate, non-US schools, 2025
Source: USMLE Performance Data, Step 1 administrations (usmle.org/performance-data)
29,870 from US MD and DO schools plus 25,660 from non-US schools
Total Step 1 examinees, 2025
Source: USMLE Performance Data, Step 1 administrations (usmle.org/performance-data)
196 on the retired three-digit scale, with USMLE stating that examinees typically must answer approximately 60 per cent of items correctly
Passing standard
Source: USMLE, Examination Results and Scoring (usmle.org/scores-transcripts/examination-results-and-scoring)
695 dollars, plus a 210 dollar region fee for exams taken outside the United States and Canada, and an 18 per cent Indian goods and services tax for the India testing region
Application fee, 2026 and 2027
Source: USMLE, Apply for Exams (usmle.org/apply-exams)
Approximately 335 US and Canadian Prometric centres, approximately 100 international centres, plus centres at four US medical schools
Test centre network
Source: USMLE Performance Data, USMLE Administration section (usmle.org/performance-data)
If you fail
Wait before retaking
There is no fixed minimum gap between the first three attempts, but you may not take the same Step more than three times within any 12-month period. A fourth attempt must be at least 12 months after your first attempt at that exam and at least six months after your most recent attempt. Incomplete attempts count.
Attempt limit
Four attempts at a single Step, incompletes included. USMLE states that if you have attempted a Step four or more times without passing, you are ineligible to apply for any Step in the USMLE sequence. Attempts at the retired Step 2 Clinical Skills count toward the limit. Separately, if you pass a Step you are not permitted to retake it, except to satisfy a time limit imposed by a US licensing authority or another recognised authority.
Retake fee
The full application fee again: 695 dollars for 2026 and 2027, plus the 210 dollar region fee if you test outside the United States and Canada. Prometric change fees apply on top if you move the appointment: no fee 46 or more days out, 35 dollars at 31 to 45 days, 100 dollars at 6 to 30 days, and 158 dollars for Step 1 within 5 days, on the schedule effective 1 July 2026.
A failing score report includes performance feedback by content area, which is the only diagnostic USMLE gives you. Open every block even if you have nothing left to give one: USMLE states that if you do not open every block your examination may not be scored and the attempt may be reported as an incomplete on your transcript, and incompletes still count against the four-attempt limit. Score rechecks are available for a fee if requested within 90 days of your result being released, but USMLE states the recheck has never produced a score change and does not involve manual review of your answers. USMLE also warns that anomalous performance or an unusual testing history can trigger a review of your eligibility, and that sitting a Step for familiarisation rather than to pass is prohibited. If you cannot test inside your three-month eligibility period, request the one-time contiguous extension from your registration entity rather than letting the period lapse, because a lapsed period means a new application and a new fee.
Exam Domains & Topics
The largest published system band on Step 1, combining reproductive and endocrine pathology, physiology and the mechanisms of the drugs used to treat both.
Key Topics to Master:
- Hypothalamic-pituitary axes and feedback loops
- Thyroid and parathyroid disorders
- Adrenal cortex and medulla pathology
- Diabetes mellitus mechanisms and drug targets
- Menstrual cycle physiology and its disorders
- Pregnancy, placentation and teratogenesis
- Sex hormone synthesis pathways and enzyme deficiencies
Two systems grouped in one published band because acid-base balance, oxygen delivery and volume regulation cut across both.
Key Topics to Master:
- Acid-base disorders and compensation
- Oxygen-haemoglobin dissociation curve
- Obstructive versus restrictive lung disease patterns
- Glomerular disease histology
- Nephron transport and diuretic sites of action
- Renin-angiotensin-aldosterone system
- Pulmonary embolism and V/Q mismatch
Neuroanatomy, neurophysiology, psychiatric disease mechanisms and the pharmacology of drugs acting on the central nervous system, plus eye and ear.
Key Topics to Master:
- Brainstem and cranial nerve lesion localisation
- Spinal cord tracts and lesion syndromes
- Neurotransmitter systems and receptor pharmacology
- Neurodegenerative disease pathology
- Defence mechanisms and psychiatric diagnostic criteria
- Substance use and withdrawal syndromes
- Visual field defects and hearing loss patterns
USMLE publishes these as two separate rows, biostatistics and epidemiology or population health at 4 to 6 per cent and social sciences covering communication and interpersonal skills at 6 to 9 per cent. They are grouped here because both sit outside the organ-system structure.
Key Topics to Master:
- Study design identification, including case series versus cohort
- Sensitivity, specificity and predictive values
- Bias, confounding and effect modification
- Hypothesis testing, confidence intervals and p values
- Research ethics and informed consent
- Physician communication and the most appropriate initial statement
- Screening principles and lead-time bias
Haematology and immunology, including the immune deficiency and hypersensitivity content that Step 1 tests heavily through mechanism-based vignettes.
Key Topics to Master:
- Anaemia classification by mean corpuscular volume
- Haemoglobinopathies and thalassaemias
- Coagulation cascade and bleeding disorder panels
- Leukaemia and lymphoma cell markers
- Hypersensitivity reaction types
- Primary immunodeficiencies
- Complement pathway defects
Bone, joint, muscle, connective tissue and dermatological pathology, including the autoimmune connective tissue diseases and their antibody profiles.
Key Topics to Master:
- Muscle contraction physiology and neuromuscular junction disease
- Rheumatoid arthritis, osteoarthritis and gout crystal findings
- Autoantibody patterns in connective tissue disease
- Bone remodelling, osteoporosis and osteopetrosis
- Collagen synthesis defects
- Skin cancer histology
- Bullous and blistering skin diseases
Content that does not sit inside one organ system, including genetics, nutrition, infectious disease spread across systems, and the general principles of neoplasia.
Key Topics to Master:
- Inheritance patterns and pedigree analysis
- Trinucleotide repeat and imprinting disorders
- Vitamin deficiency syndromes
- Sepsis and shock physiology
- Tumour suppressor genes and oncogenes
- Paraneoplastic syndromes
- Systemic infections and their organ manifestations
Cardiac physiology, vascular pathology and cardiovascular pharmacology, with heavy use of pressure-volume loops and haemodynamic tables.
Key Topics to Master:
- Cardiac cycle and pressure-volume loops
- Preload, afterload and contractility manipulation
- Murmur identification and manoeuvres
- Congenital heart defects and shunt physiology
- Atherosclerosis and ischaemic injury timelines
- Antiarrhythmic drug classes and mechanisms
- Shock states and their haemodynamic profiles
Gut and hepatobiliary pathology and physiology, including the embryology that explains congenital anomalies.
Key Topics to Master:
- Gastrointestinal embryology and rotation anomalies
- Peptic ulcer disease and Helicobacter pylori
- Inflammatory bowel disease distinguishing features
- Liver function tests and bilirubin metabolism
- Cirrhosis and portal hypertension consequences
- Malabsorption syndromes
- Pancreatic enzyme physiology and pancreatitis
The smallest published band. USMLE notes it covers normal age-related findings and care of the well patient, and that the rest of the former General Principles category was redistributed into organ systems by disease process.
Key Topics to Master:
- Normal developmental milestones
- Age-related physiological changes
- Care of the well patient
- Normal ageing versus pathology
- Preventive care principles
Recommended Study Plan
- 1Sit an NBME Comprehensive Basic Science Self-Assessment form under timed conditions before studying anything, so you have a real starting number rather than a guess.
- 2Download the USMLE Content Outline and the Physician Tasks and Competencies PDF from usmle.org and mark which of the eleven published system bands you are weakest in.
- 3Run the Step 1 interactive testing experience on usmle.org and complete the free 120 sample items to learn the interface you will actually face, including the 30-minute block structure if your date is on or after 14 May 2026.
- 4Set your UWorld Step 1 question bank to tutor mode, random, timed, and calculate how many questions per day you need to finish the bank once before your date.
- 5Book your Prometric appointment as soon as your scheduling permit arrives, because appointments are first-come, first-served and rescheduling inside 45 days carries a fee.
- 1Work through the Pathoma chapters on growth adaptations, cellular injury, inflammation and neoplasia, which carry into every organ system.
- 2Annotate the corresponding First Aid for the USMLE Step 1 pages rather than making separate notes, so you have one reviewable source.
- 3Complete 80 UWorld questions on general pathology and read every explanation, including the ones you answered correctly.
- 4Start or resume an AnKing Anki deck filtered to the tags for the chapters you covered, and hold your daily review count steady rather than adding faster than you can review.
- 5Write down every mechanism you could not explain out loud, and revisit that list at the end of the week.
- 1Cover cardiac physiology through Boards and Beyond, focusing on pressure-volume loops and the effect of each drug class on preload, afterload and contractility.
- 2Drill murmur manoeuvres until you can predict the direction of change without hesitation, because Step 1 asks for the change, not the name.
- 3Do 120 mixed UWorld questions across cardiology and pulmonology in timed blocks of 20, matching the block size you will see on test day.
- 4Build a one-page acid-base algorithm and test it against every acid-base question you have seen.
- 5Review the haemodynamic table format from the USMLE sample items, where the answer is a row of arrows rather than a diagnosis.
- 1Map every diuretic and antihypertensive to its nephron segment and draw the map from memory twice.
- 2Work the endocrine axes as feedback diagrams, then test yourself with primary versus secondary versus tertiary pattern questions.
- 3Complete 120 UWorld questions across renal, endocrine and reproductive, keeping to 30-minute timed blocks.
- 4Review steroid synthesis enzyme deficiencies alongside their clinical presentations, since the reproductive and endocrine band is the largest on the published blueprint at 12 to 16 per cent.
- 5Add Anki cards only for the facts you missed twice, not for everything you read.
- 1Work through the Sketchy Micro videos for bacteria and viruses, then immediately answer questions on the same organisms rather than watching more videos.
- 2Build a table of hypersensitivity reaction types with two examples each and recall it cold.
- 3Complete 120 UWorld questions on microbiology and immunology in timed blocks.
- 4Link each primary immunodeficiency to the specific infections it predisposes to, because Step 1 asks the mechanism through the infection pattern.
- 5Sit a second NBME Comprehensive Basic Science Self-Assessment form to check whether your baseline has moved.
- 1Concentrate on mechanisms of action rather than dosing or drug interactions, because USMLE states the pharmacology content focuses primarily on mechanisms.
- 2Use Sketchy Pharm for the drug classes you keep confusing, then test with mixed questions rather than class-by-class blocks.
- 3Practise brainstem and spinal cord lesion localisation with cross-sectional diagrams until you can name the tract from the deficit.
- 4Complete 120 UWorld questions across pharmacology and neurology in 30-minute timed blocks.
- 5Review the neurotransmitter and receptor tables in First Aid alongside the psychiatric drug classes.
- 1Cover gastrointestinal embryology together with the congenital anomalies it explains, rather than as separate topics.
- 2Learn liver function test patterns as panels, since Step 1 gives you the panel and asks for the mechanism.
- 3Work the anaemia algorithm from mean corpuscular volume through to the specific diagnosis, then reverse it.
- 4Complete 120 UWorld questions across these four areas in timed blocks.
- 5Review autoantibody profiles for connective tissue disease and the skin findings that accompany them.
- 1Practise identifying study designs from a description, using the USMLE sample item on acupuncture in children as the model for how the question is phrased.
- 2Calculate sensitivity, specificity, positive predictive value and negative predictive value from two-by-two tables until it is automatic.
- 3Work through communication items by eliminating options that shut down the conversation, which is the pattern in the USMLE published examples.
- 4Complete 80 UWorld questions on biostatistics, epidemiology and behavioural science.
- 5Sit a third NBME self-assessment and compare your weakest system band against the published blueprint weights.
- 1Sit a full 280-question simulation in the exact block structure of your test date, either fourteen 30-minute blocks or seven 60-minute blocks.
- 2Practise the break economy: bank minutes by finishing blocks early, and rehearse eating and drinking within the 55 minutes you will have.
- 3Review every missed question by mechanism, not by fact, and group the misses into no more than five themes.
- 4Do a second full-length day later in the week to test whether your accuracy holds in blocks eleven through fourteen.
- 5Confirm your scheduling permit name matches your government photo identification exactly, since a mismatch means you will not be admitted.
- 1Review only your own annotated First Aid and your missed-question themes; do not open new material.
- 2Sit the NBME Free 120 as the final check, since it is written by the same organisation that writes the exam.
- 3Do light, mixed, timed blocks each morning to keep timing calibrated, then stop by early afternoon.
- 4Pack your scheduling permit on paper or on your phone, your unexpired government photo identification with signature and photograph, and a clear unlabelled water bottle.
- 5Arrive at the Prometric centre about 30 minutes early; arriving more than 30 minutes after your appointment time means you will not be admitted and will pay a fee to reschedule.
Ready to pass USMLE Step 1?
Get 500+ practice questions, video walkthroughs, and a pass guarantee.
Best Study Resources
USMLE Content Outline and Physician Tasks and Competencies
Official specificationThe two PDFs USMLE publishes on the Step 1 exam content page, giving the eleven system bands with their percentage ranges and the four competency bands. Free.
Step 1 interactive testing experience and sample items
Official practice softwareMore than 100 sample Step 1 items delivered in the real interface. USMLE states the tutorial on test day has fewer screens than this one, and that it includes items with associated audio findings you should meet before test day. Free.
NBME Comprehensive Basic Science Self-Assessments
Official practice examPaid self-assessment forms written by the same organisation that writes Step 1 items, delivered in the same software as the current test. The standard reference point for readiness.
First Aid for the USMLE Step 1
Review bookThe annually revised McGraw Hill review book that most candidates use as the single annotation target. Organised by general principles then organ system, which mirrors the USMLE content outline.
UWorld Step 1 Qbank
Question bankThe most widely used commercial question bank for Step 1, with tutor and timed modes and explanations that teach the mechanism behind each option.
Pathoma: Fundamentals of Pathology
Video and text courseHusain Sattar's pathology course. Useful because USMLE classifies 45 to 55 per cent of Step 1 items to the discipline of pathology, the largest single discipline band.
Sketchy Medical
Visual mnemonic courseIllustrated mnemonic videos for microbiology and pharmacology, the two disciplines where Step 1 asks for organism and mechanism recall under time pressure.
AMBOSS
Question bank and reference libraryA question bank paired with a linked medical library, so an unfamiliar term in a vignette can be opened without leaving the question.
Boards and Beyond
Video courseJason Ryan's video series covering basic science by system, commonly used as the first pass before question banks.
AnKing Step 1 Anki deck
Spaced repetition deckA community-maintained Anki deck tagged to First Aid, Pathoma, Sketchy and Boards and Beyond, so cards can be unsuspended in step with whatever you are covering.
Common Mistakes to Avoid
Studying by discipline when the exam is built by organ system.
USMLE constructs Step 1 from an integrated outline organised by system, and states that most items classify to more than one discipline, which is why its discipline table totals over 100 per cent.
Memorising drug doses, interactions and adverse effects.
USMLE states explicitly that the pharmacology content focuses primarily on mechanisms of action rather than specific pharmacotherapy, drug-drug interactions, adverse effects or contraindications.
Leaving items blank.
USMLE's own strategy guidance says unanswered questions are automatically counted as wrong, so a guess costs nothing and a blank always costs a point.
Not opening every block.
USMLE warns that if you do not open every block, the exam may not be scored and the attempt may be reported as incomplete on your transcript, and incompletes count toward the four-attempt limit.
Practising in 60-minute blocks for an exam that now runs in 30-minute blocks.
Any Step 1 taken on or after 14 May 2026 uses fourteen 30-minute blocks of up to 20 items, and the review window closes at the end of each block.
Assuming you can go back to an earlier block.
The software lets you review items only within the block you are in; once a block closes you cannot return to it, in both the old and new interfaces.
Testing before self-assessment scores are stable.
Because a fourth failed or incomplete attempt ends eligibility for the entire USMLE sequence, one weak NBME form close to your date is a reason to reschedule, not to push through.
Registering with a name that does not exactly match your photo identification.
USMLE requires the name on the scheduling permit to match the identification exactly, and name changes must be processed no later than seven business days before the appointment.
Treating the retired three-digit score as the target.
Step 1 has reported pass or fail only since 26 January 2022, and USMLE has said future reviews of the passing standard will not be expressed as a three-digit score.
Ignoring the audio items.
The interactive testing experience includes items with associated audio findings, and the sound check must be run before the exam begins or during the tutorial so problems can be fixed before scoring time starts.
Exam Day Tips
- 1
Arrive about 30 minutes before your appointment. USMLE states that arriving after your appointment time may mean you are not admitted, and arriving more than 30 minutes late means you will not be admitted and must pay a fee to reschedule inside your eligibility period.
- 2
Bring your scheduling permit, on paper or on a phone, plus valid unexpired government-issued photo identification carrying both your signature and a recent photograph. A passport, driving licence with photograph or national identity card all qualify. Without both documents you will not be admitted.
- 3
Expect biometric check-in. Test centre staff scan you with a handheld or walk-through detector, ask you to turn your pockets inside out, may scan your photo identification and fingerprint electronically, and require you to sign the centre log every time you enter or leave the test room.
- 4
Remove and hand over your eyeglasses for inspection at check-in and after every break. Jewellery other than wedding and engagement rings is prohibited, and hair clips, combs, barrettes and headbands are subject to inspection.
- 5
You get laminated writing surfaces and markers, and nothing else. Write on those only, never on skin, clothing or tissue, since USMLE treats that as possible irregular behaviour. Raise your hand for a replacement board when you fill one, and hand everything back at the end.
- 6
Write your name and CIN on a laminated board as instructed, and enter your CIN into the computer to start. You will need the CIN again if the unauthorised break screen appears after a period of inactivity.
- 7
Water is allowed in a clear or transparent container with a lid and all labels removed, and cordless soft-foam earplugs without strings are on the pre-approved list. Everything else goes in the small locker outside the secure area, with electronics switched off rather than silenced.
- 8
Manage the break bank deliberately. The newer format allots a minimum of 55 minutes of break plus a 5-minute optional tutorial, and any minutes you save by finishing a block or the tutorial early are added to your break time. Exceeding your accumulated break time is deducted from testing time.
- 9
Do not leave the room mid-block. Once a block starts you may not leave except in an emergency, and an unauthorised departure keeps both the block clock and the day clock running and is reported to the USMLE program.
- 10
Run the headphone sound check before the exam or during the tutorial, because some items carry audio findings and a hardware problem discovered mid-block wastes scored minutes.
- 11
Answer every item before the block closes. Guessing costs nothing, blanks are scored wrong, and you cannot reopen a closed block.
Career Paths & Salary Ranges
Resident physician, PGY-1
The first postgraduate year, entered after passing Step 1 and Step 2 CK and matching into an ACGME-accredited programme. The figure is the projected 2025 PGY-1 stipend used in the AAMC's own Living on a Resident's Budget material; actual stipends are set by the sponsoring institution and collected annually in the AAMC Survey of Resident and Fellow Stipends and Benefits. Most residents take Step 3 during PGY-1 or PGY-2.
About 67,000 dollars a year
General paediatrician
Three years of residency after medical school. The lowest mean annual wage of the seventeen physician specialties the US Bureau of Labor Statistics reported for May 2024, and one of the two specialties BLS projects growing only 1 per cent between 2024 and 2034.
Mean 222,340 dollars a year
Family medicine physician
The largest single physician specialty BLS tracks, at 116,000 jobs in 2024 and a projected 119,100 by 2034. Three years of residency, and the most common destination for graduates who want the widest geographic choice.
Mean 256,830 dollars a year
Psychiatrist
Four years of residency. BLS projects psychiatrist employment growing 6 per cent from 27,100 in 2024 to 28,800 in 2034, tied with dermatology for the fastest projected growth among the physician specialties it reports.
Mean 269,120 dollars a year
Anaesthesiologist
Four years of residency after an intern year. BLS counted 45,300 anaesthesiologists in 2024 with 46,700 projected for 2034.
Mean 336,640 dollars a year
Pediatric surgeon
The highest mean annual wage among the physician specialties BLS reported for May 2024, and also the smallest, at 1,100 jobs in 2024 with no net growth projected to 2034. Requires general surgery residency followed by paediatric surgery fellowship.
Mean 450,810 dollars a year
Prerequisites & Requirements
- There is no coursework requirement, no minimum grade and no experience requirement for Step 1. What USMLE requires is a category of enrolment, both at the time you apply and on the day you test. You must be a medical student officially enrolled in, or a graduate of, a US medical school leading to the MD degree accredited by the LCME; or a student or graduate of a US medical school leading to the DO degree accredited by COCA; or a student or graduate of a medical school outside the United States that is listed in the World Directory of Medical Schools as meeting ECFMG eligibility requirements and that meets ECFMG's other criteria. International medical graduates must have an accepted Application for ECFMG Certification before applying for their first Step exam, and their name of record with FSMB must exactly match their name of record with Intealth. Since January 2026, students and graduates of LCME and COCA-accredited US programmes register through NBME's MyUSMLE Portal, and everyone else registers through FSMB. Individuals who graduated from Canadian medical schools on or after 1 July 2025 are treated as international medical graduates. If you are dismissed from or withdraw from medical school you lose eligibility immediately, even while appealing, and failing to report a change in status can be treated as irregular behaviour. Anyone already licensed by a US medical board on the basis of other examinations, such as FLEX, MCCQE, NBME Parts or COMLEX-USA, may not be eligible at all.
Frequently Asked Questions
How much does USMLE Step 1 cost?
The application fee is 695 dollars for 2026 and 2027, whether you register through NBME or FSMB. Anyone testing outside the United States and Canada pays an additional 210 dollar region fee, which USMLE notes is not a USMLE fee. Candidates who select the India testing region also pay an 18 per cent Indian goods and services tax, collected under Notification No. 28/2023-Central Tax and remitted directly to India. Fees are non-refundable and non-transferable.
What happens if I fail Step 1?
You receive a failing score report that includes content-area performance feedback, and you may reapply and retest. You may not take Step 1 more than three times in any 12-month period, and a fourth attempt must fall at least 12 months after your first attempt and at least six months after your most recent one. Each retake costs the full 695 dollar application fee again. Four unsuccessful attempts, incompletes included, end your eligibility for every Step in the USMLE sequence permanently.
How long do I have to wait to retake Step 1?
There is no mandated gap between your first, second and third attempts beyond the rule that no more than three attempts may fall inside any 12-month period. Practically, the wait is driven by processing: you submit a new application, receive a new scheduling permit for a three-month eligibility period, and book with Prometric. The hard wait applies only to a fourth attempt, which must be at least 12 months after the first attempt and at least six months after the most recent one.
Is Step 1 scored or pass/fail?
Pass or fail only, for every exam administered on or after 26 January 2022. No three-digit score is released to you, to your medical school, or to residency programmes. Step 2 CK and Step 3 still report three-digit scores, with minimum passing scores of 218 for Step 2 CK from 1 July 2025 and 200 for Step 3 from 1 January 2024.
What percentage do I need to pass Step 1?
USMLE states that examinees typically must answer approximately 60 per cent of items correctly to achieve a passing score, and that the exact percentage varies by Step and from form to form because forms are statistically equated. On the retired three-digit scale the Step 1 passing standard is 196. Because the standard is fixed to a proficiency level rather than to a percentile, no predetermined percentage of examinees passes or fails.
When do Step 1 results arrive?
Typically within four weeks of your test date, though USMLE advises allowing at least eight weeks when planning around a result. Scores are processed continuously and released weekly. You will receive an email from NBME if you are a US medical school student or graduate, or from FSMB if you are an international medical graduate, and the report stays available on that portal for approximately 365 days.
How many questions are on Step 1 and how long is the exam?
Up to 280 multiple-choice items in one 8-hour session. From 14 May 2026 the exam runs as fourteen 30-minute blocks of up to 20 items, giving 420 minutes of testing time plus a minimum 55 minutes of break and a 5-minute optional tutorial. Before that date it ran as seven 60-minute blocks of up to 40 items with a 45-minute break minimum and a 15-minute tutorial. USMLE confirmed the content, item count and day length are unchanged.
What identification do I need at the test centre?
Your scheduling permit, on paper or on a phone, and valid unexpired government-issued photo identification bearing both your signature and a recent photograph. A passport, a driving licence with photograph, or a national identity card are all listed as acceptable. The name on your identification must exactly match the name on your scheduling permit. Missing either document means you will not be admitted and will pay a fee to reschedule.
Is Step 1 offered with online proctoring at home?
No. Step 1 is delivered only at authorised Prometric test centres, with in-person biometric check-in that can include electronic scanning of your photo identification and fingerprint. Check-in also involves a handheld or walk-through metal detection scan, emptying your pockets, and repeating the process each time you return from a break.
What can I bring into the testing room?
Your locker key and your identification. Test centre staff issue laminated writing surfaces and markers for notes and calculations. A pre-approved items list on the USMLE site permits things such as cordless soft-foam earplugs without strings, water in a clear container with the lid on and all labels removed, and certain medicines or medical devices, all subject to inspection. Everything else stays in the locker outside the secure area, with electronics powered off rather than muted.
Is a calculator allowed on Step 1?
USMLE does not permit personal calculators in the testing room. Notes and calculations are made on the laminated writing surfaces provided, and the testing software includes on-screen tools that you should learn in the Step 1 interactive testing experience before test day rather than discovering mid-block.
How do I request test accommodations?
Select the test accommodations option on your Step exam application, which places a temporary hold on your scheduling permit, then submit the request with documentation to Disability Services through your registration entity's portal. USMLE advises allowing approximately 60 business days for a decision and recommends applying as early as possible. Requests for additional break time only, for reasons such as diabetes management or expressing milk, follow the same route. Accommodations are provided under the Americans with Disabilities Act.
Can I cancel or reschedule after I start the exam?
No. USMLE states that once you start an examination you cannot cancel or reschedule it. Before test day, Prometric charges nothing to change an appointment 46 or more days out, 35 dollars at 31 to 45 days, 100 dollars at 6 to 30 days, and 158 dollars for Step 1 within 5 days, under the schedule effective 1 July 2026. Changes must be made by the day before the exam, never on the day itself, and the new date must fall inside your eligibility period.
Does Step 1 expire, and is there recertification or continuing education?
There is no recertification and no continuing education requirement for Step 1 itself; a pass is permanent on your USMLE transcript. What does expire is the window around it. Most US medical licensing authorities require all three Steps to be completed within a seven-year period beginning when you pass your first Step, and USMLE recommends that jurisdictions consider exceptions for MD and PhD dual-degree candidates who meet specified conditions. Continuing medical education requirements attach later, to state licences and specialty board certification, not to the USMLE.
Can I retake Step 1 to improve my result?
No. USMLE prohibits retaking a Step you have already passed, except to comply with a time limit imposed by a US medical licensing authority or another authority recognised by the USMLE program for that purpose. Since Step 1 reports pass or fail only, there is no score to improve. If you do retake a previously passed Step 1 to meet a time limit and fail the retake, you become ineligible for Step 3.
How does Step 1 compare with Step 2 CK?
Step 1 tests basic science mechanisms and reports pass or fail; Step 2 CK tests clinical knowledge and still reports a three-digit score, with a minimum passing score of 218 from 1 July 2025. Step 2 CK is longer: 316 items in a 9-hour day, delivered as sixteen 30-minute blocks from 7 May 2026, against Step 1's 280 items in an 8-hour day. Pass rates diverge sharply. In 2024-25 USMLE reported 98 per cent of first-time US MD takers passing Step 2 CK against 93 per cent for Step 1 in 2025, and 90 per cent of non-US first-time takers against 75 per cent.
Who registers me for Step 1, NBME or FSMB?
Students and graduates of LCME or COCA-accredited US programmes register through NBME's MyUSMLE Portal. Everyone else, including graduates of Canadian medical schools who graduated on or after 1 July 2025, registers through FSMB. This split took effect on 12 January 2026, when Step 1 and Step 2 CK services for international medical graduates moved from ECFMG to FSMB, and on 26 January 2026 for Step 3 services moving from FSMB to NBME. ECFMG still manages the Certification process itself.
What is an incomplete attempt and why does it matter?
If you do not open every block of your exam, USMLE may not score it and the attempt may be recorded as incomplete on your transcript. Incompletes count toward the four-attempt limit exactly as failures do. If you start an exam and do not finish for any reason other than a technical fault or expiry of time, you should write to Test Administration Services at NBME promptly explaining why, and technical problems must be reported within 10 days of the test date.
Can I stop my medical school from seeing my result?
Yes, but only in advance. NBME reports Step results to LCME and COCA-accredited schools for their students and graduates. To withhold a Step 1 result, US students and graduates must email [email protected] from their email account of record at least 10 business days before the scheduled test date, and a separate request is needed for each administration. International medical graduates specify the preference on the application itself. De-identified results may still appear in aggregate reports to schools.
How many practice questions should I do before testing?
USMLE does not publish a recommended number, and no vendor figure should be treated as a threshold. What USMLE does provide as a calibration point is free: more than 100 sample items in the interactive testing experience delivered in the real interface, plus the paid NBME Comprehensive Basic Science Self-Assessments written by the same organisation that writes the exam. Those self-assessment forms are the closest available approximation of the real standard, which is why sitting one before and one near the end of a study block is the usual practice.
Success Stories
“Did 2 passes of UWorld and watched all of Pathoma twice. First Aid was my bible. Take practice NBMEs seriously - they predict your readiness well.”
Rachel K.
Medical Student
“Anki every day for 8 months before dedicated. During dedicated, focused on UWorld incorrects and weak areas. The pass/fail change reduced stress significantly.”
James L.
Medical Student
“Sketchy was a lifesaver for micro and pharm. Don't underestimate biostatistics and ethics - easy points if you study them.”
Priya M.
Medical Student
Pass USMLE Step 1, Guaranteed
94% pass rate on first attempt
One-time • Lifetime access