The United States Medical Licensing Examination Step 1 (USMLE® Step 1) is one of three exams in the USMLE® sequence required for medical licensure in the United States. Administered jointly by the National Board of Medical Examiners (NBME) and the Federation of State Medical Boards (FSMB), Step 1 assesses your understanding of the foundational biomedical sciences that underpin clinical medicine. As of January 2022, USMLE® Step 1 is scored on a pass/fail basis, a major shift from the previous three-digit numeric score. This page covers what the exam tests, how pass/fail scoring works, when to take it, how to prepare, and the best free resources available.
The Shift to Pass/Fail Scoring
Before January 2022, USMLE® Step 1 was scored on a three-digit scale (with a mean around 230 and a passing score around 194), and many residency programs used the Step 1 score as a primary filter in their selection process. The transition to pass/fail was driven by concerns about the outsized role a single exam score played in residency selection, the negative effects on student wellbeing, and the way numeric scoring contributed to a narrowing of medical education as students optimized for test performance over broader learning.
Under the pass/fail model, your result is reported as either Pass or Fail. There is no numeric score. This means residency programs can no longer use Step 1 as a screening tool based on a specific score threshold. Instead, programs are placing greater weight on clinical clerkship performance (Step 2 CK scores, clinical grades, Dean’s letters), research, extracurricular involvement, and letters of recommendation. For current and future medical students, this shift means that Step 2 CK has become the primary scored USMLE® exam for residency applications.
Exam Format and Content
USMLE® Step 1 is a one-day, computer-based exam consisting of approximately 280 multiple-choice questions divided into seven 40-question blocks, each with a 60-minute time limit. Total testing time is approximately 7 hours, plus a 45-minute break period that you can allocate flexibly between blocks.
The exam covers the foundational sciences taught during the first two years of medical school. Content areas include anatomy, behavioral sciences, biochemistry, biostatistics and epidemiology, microbiology, pathology, pharmacology, and physiology. Questions are organized around organ systems and general principles, and they frequently require you to integrate knowledge across multiple disciplines. A clinical vignette format is used for most questions, meaning you will read a short patient scenario and apply your scientific knowledge to answer the question.
High-yield topics that appear frequently include pathophysiology of common diseases, mechanisms of action of major drug classes, microbial virulence factors and antimicrobial resistance, biochemical pathways (glycolysis, citric acid cycle, urea cycle, lipid metabolism), embryology of key organ systems, and foundational biostatistics concepts (sensitivity, specificity, positive predictive value, study design types).
Eligibility and Registration
USMLE® Step 1 is typically taken by medical students enrolled in LCME-accredited (MD) programs in the United States and Canada, as well as international medical graduates (IMGs). Most MD students take Step 1 at the end of their second year of medical school (the preclinical phase), though the exact timing varies by school curriculum. Some schools with integrated or systems-based curricula schedule the exam at different points.
Registration is managed through the NBME website. After registering and receiving your scheduling permit, you can schedule your exam at a Prometric testing center for a date within your eligibility period (typically a three-month window). The exam fee is approximately $645 for U.S. and Canadian students and $960 for IMGs, though these amounts are subject to change. Check the USMLE® website for current fees.
How to Prepare
Most students dedicate 4 to 8 weeks of full-time, focused study to Step 1 preparation. Many schools build a dedicated study block into the curriculum for this purpose. During this period, you will typically study 8 to 12 hours per day, combining content review, question practice, and spaced repetition. The exact amount of time you need depends on your baseline knowledge coming out of your preclinical courses, your performance on practice exams, and whether you are aiming simply to pass or to build a strong foundation that supports your Step 2 CK preparation.
Even though Step 1 is now pass/fail, you should still take the exam seriously and prepare thoroughly. Failing Step 1 can delay your progression through medical school, complicate your residency application, and require you to retake the exam. A solid Step 1 foundation also makes Step 2 CK preparation significantly easier, because many of the same concepts reappear in a clinical context.
Recommended Study Resources (Free First)
NBME Self-Assessments (Free and Paid): The NBME offers several self-assessment exams (also called practice forms) that use retired Step 1 questions. Some forms are available for free. These are the closest approximation of the real exam and serve as the best predictor of your readiness. Take one early as a diagnostic and another one or two in the final weeks of your study period.
Pathoma (Low Cost): Pathoma is a widely used video series and companion text covering pathology and pathophysiology. While not free, it is relatively affordable compared to other commercial resources and is considered by many medical students to be one of the highest-yield Step 1 resources available. If your school does not provide institutional access, consider this a worthwhile investment.
Anki Flashcard Decks (Free): Community-created Anki decks (such as the AnKing deck, which integrates content from multiple popular review resources) are widely used by medical students for spaced-repetition review. Using Anki consistently throughout your preclinical years, rather than only during a dedicated study block, is one of the most effective long-term retention strategies. See our spaced repetition guide.
Khan Academy® (Free): Khan Academy® provides free content covering many of the foundational science topics tested on Step 1, including biochemistry, cell biology, and physiology. It is particularly useful for reviewing concepts you learned in your undergraduate courses if you need a refresher. See our Khan Academy® guide.
Question Banks (Paid): Most medical students use at least one commercial question bank during their Step 1 preparation. These products provide thousands of practice questions with detailed explanations, organized by subject and system. We do not recommend specific commercial providers and do not place affiliate links. Choose a question bank based on recommendations from upperclassmen at your school and your own experience with the question style. Complete at least one full pass through your chosen question bank during your study period.
Study Strategies
Content Review: Work through a review resource (text-based or video-based) that covers all the major Step 1 topics. Supplement with your school’s lecture materials for topics that were covered well in your courses. Do not attempt to re-read entire textbooks. Focus on high-yield summaries and integration across disciplines. Pathology, pharmacology, and biochemistry are typically the highest-yield content areas.
Practice Questions: Do questions every day, starting from the first day of your study period. Questions are the most important component of Step 1 preparation because they teach you to apply knowledge in the clinical vignette format. Review every question you get wrong (and many you get right) to understand the reasoning behind the correct answer and to fill knowledge gaps.
Spaced Repetition: Use Anki daily to reinforce high-yield facts and concepts. If you have been using Anki throughout your preclinical years, continue your daily reviews during the study block. If you are starting Anki for the first time, focus on the highest-yield cards and aim for consistency over volume.
Practice Exams: Take at least two to three full-length NBME self-assessments during your study period. These provide the best estimate of your readiness. If your scores are consistently above the passing threshold, you are likely ready. If you are close to or below the passing line, consider extending your study period.
What Happens After Step 1
After passing Step 1, you will move into your clinical clerkship years (third and fourth year of medical school). During this period, you will prepare for and take USMLE® Step 2 Clinical Knowledge (CK), which is now the primary scored exam used in residency selection. See our USMLE® Step 2 preparation guide for details. If you do not pass Step 1, you will need to retake it. Most schools have policies governing retake timing and requirements. Speak with your school’s academic support office immediately if you receive a Fail result.
References
United States Medical Licensing Examination (USMLE). “Step 1.” USMLE, 2025. https://www.usmle.org/step-exams/step-1. Accessed March 2026.
National Board of Medical Examiners (NBME). “Self-Assessments.” NBME, 2025. https://www.nbme.org/assessment-products/self-assessments. Accessed March 2026.
Federation of State Medical Boards (FSMB). “USMLE Score Reporting.” FSMB, 2025. https://www.fsmb.org/. Accessed March 2026.
Khan Academy. “Health and Medicine.” Khan Academy, 2025. https://www.khanacademy.org/science/health-and-medicine. Accessed March 2026.