This guide is intended for medical students who are curious about working in the U.S., have considered sitting the exams required to practice there or are simply considering doing clinical electives in the U.S.

“The United States Medical Licensing Examination ® (USMLE®) is a three-step examination for medical licensure in the U.S. The USMLE assesses a physician's ability to apply knowledge, concepts, and principles, and to demonstrate fundamental patient-centred skills, that are important in health and disease and that constitute the basis of safe and effective patient care.” - USMLE.ORG

What is STEP 1 for the USMLE® and why should I consider it?

STEP 1 is the first of three computer-based multiple choice exam papers that a medical student must sit to apply for residency positions in U.S. hospitals. It is intended to test the “pre-clinical” sciences: anatomy, physiology, pharmacology, biochemistry, and pathology to a level expected of a student about to enter their clinical rotations.

Most students who take the exam are one of three categories:

• U.S. medical students who must take these exams to complete medical school;
• U.S. citizens studying in international medical schools who intend to train and work in the U.S.;
• International medical students or graduates (of any other citizenship) who would like to do electives in U.S. hospitals or apply to train and work in the U.S. If you’re reading this from Australia - this is probably you!

It is regarded as the most important exam that U.S. medical students will undertake to be matched to their desired programs. The exam is delivered over 8 hours, with 280 Multiple Choice Questions divided across 7 blocks of 40 questions.

When can I take the exam?

The first exam (STEP 1) is available to any medical student who has completed and passed the first 2 years of a 4 year medical school program. If your medical program is an undergraduate program, the rules regarding eligibility can be different. In this instance, you should consult with your school.

How do I apply for the exam?

First, you should ensure that the U.S. medical system recognises your medical school as eligible according to the LCME (Liaison Committee on Medical Education) and is registered with the World Directory of Medical Schools. You can check here by typing in Australia.

Then you apply to the Educational Commission for Foreign Medical Graduates (ECFMG) which oversees the registration of international students and graduates. You also need to inform your own medical school that they will be contacted by the ECFMG to verify that you are enrolled and also have passed the required clinical training.

Once you have completed the various approval processes, you can select a 3 month block and then you choose a specific date and location to sit the exam. In Australia and New Zealand, the exam can be done in Sydney, Melbourne, Perth, and Auckland on several days each week, almost any week of the year. Exam slots for the end of the calendar year are usually filled about 2 months in advance. As with anything it’s important to plan in advance - try to have all your paperwork submitted at least 4 - 6 months ahead of time to allow yourself maximum flexibility.

How much does it cost?

Sitting the exam is expensive but in line with many other medical exams you can expect to pay for after graduating.

These fees are in U.S. dollars, and according to 2019 prices:

• ECFMG certification: $145 USD
• USMLE STEP 1 exam fee: $965 USD, plus $160 USD additional fee to sit the exam in Australia or New Zealand
• STEP 1 total: $1,270 USD, which approximates $1,888 AUD (at time of writing)

For a full list of fees for each step of the USMLE exams please go to: https://www.nbme.org/students/examfees.html

Note: You can be charged for rescheduling and changing location so we advise sticking to your selected time slot.

Exam fees and study resources for STEP 1 can become very expensive. You should consider what you hope to gain from the entire process, as it is quite costly if you are only undertaking it to qualify for an elective.

If you are considering the U.S. for your ongoing specialty training, a further comparison can be useful. Compare the cost breakdown listed above to the General Surgical Sciences Examination (GSSE) ($4,495 AUD) and subsequent application to a surgical college e.g. General Surgery ($880 AUD). For comparison, sitting STEP 1 and completing the subsequent USMLE exams, STEPs 2 and 3, then applying to programs in the U.S., plus visas may cost you upwards of $8,000 AUD.

Medical exam fees and career training are very expensive. As professional pathways are currently designed, there’s no way around that.

How do I study for STEP 1?

In the U.S., many medical students spend much of their 2nd year (of a 4 year program) focusing on STEP 1 to attain the highest possible scores. In the same way as many doctors spend many months studying for primary entrance exams in Australia, you should consider STEP 1 to be the crucial starting point for applying to the U.S. It will require a plan to cover a large amount of knowledge, composed of some revision from medical school as well as some new information. 

If you are a medical student in preclinical years, the best advice is to study hard for your own university exams and then add in the extra details from STEP 1 textbooks and online resources. If you are a clinical medical student or graduate, then returning to basic sciences may present a challenge. Osmosis has some of the most comprehensive resources for preparing for USMLE. Osmosis’ questions are excellent and the videos are a great introduction and revision, especially for a graduate who is coming back to medical science. They provide a flashcard app, practice questions and quick review videos.

Other resources include the lecture series from Kaplan and common textbooks that cover a great deal of core medical knowledge such as First Aid for the USMLE Step 1, and Physiology by Costanzo, and Robbins Pathology.

Additionally, good anatomy, biochemistry, microbiology and pharmacology textbooks can be equally important and useful if you have them from medical school. Specific summarised versions can often be called ‘board review’ books.

I can also recommend the sketchy medical series– a series of ‘memory palace’ style drawings that cover microbiology, pharmacology, and pathology in a way that assists memory for important generic drug classes, names, effects and side effects, clinically relevant pathogens, and their characteristics and treatments. The videos feel silly, but it is surprising how effective they can be if you are a visual learner.

The Pathoma video series and textbook summarises the majority of testable pathology and explains it intuitively with powerpoints and hand drawn illustrations.
Almost all students utilise practise question banks to get acquainted with the style and level of knowledge expected. Among the most popular of these are UWORLD, Kaplan, Pastest, AMBOSS, and USMLE Rx. These question banks can be expensive for a medical student. One budget approach is to purchase the shortest subscription length, in which you can feasibly complete all the questions and take good notes of questions you get wrong. It is important to understand what aspect of your reasoning was deficient for each incorrect answer and even for a correct answer, analyse how you made the right choice.

Refine and strengthen your reviews by directly interrogating your process:

• Did you not have the required medical knowledge for the question?
• Did the wording trick you into thinking of another diagnosis?
• Did you second guess yourself and change your answer to an incorrect option?

Learning your flaws and your best approach to answering these questions is almost as important as having all the information in the first place.

Many students also use UWORLD, and recommend doing the entire question bank a second time. However, this is not essential, as other students advocate for completing a second question bank instead, such as Kaplan or USMLE Rx. AMBOSS is a newer provider with favourable reviews, recently overtaking USMLE Rx in popularity. Another approach is to complete Kaplan or AMBOSS over a longer period of time while studying each topic i.e. anatomy and then doing the related questions, and once the broad study phase is complete, doing UWORLD at a pace of several blocks each day to prepare for the length of the actual exam.

Success on the exam for U.S. medical students has been related to medical school grade average, number of practise questions completed, and participating in a study group or tutoring preclinical students. Combining textbooks, lectures, group study and practise questions is a very effective study tactic to ensure you are strong in all areas of the exam.

In recent years, flashcard programs like Anki have become very popular to strengthen memorisation and recall of key facts through constant self-quizzing. The program is free to use and there are many decks of flashcards written by medical students based on the study resources listed above, as well as others.

The internet is full of success stories from students applying each and every one of these techniques. However, it is most important you use techniques that work for you.

Finally, the National Board of Examiners (NBME) provides six near full-length practice exams that can be taken at any time for $80 AUD each. These exams offer extensive feedback about each category of the exam, and your strengths and weaknesses. It is commonly recommended to take all six in preparation, with each sitting between 2 - 4 weeks apart in the lead up to your actual exam.

Over those 3 - 6 months, you should use the feedback to tailor your study for your weaknesses, as doing well in every area is a prerequisite for a competitive overall score. For example, even if you are a wannabe surgeon it is much easier to learn and practise basic histology questions than to improve your knowledge of anatomy.

How well do I have to do on the exam?
The National Board of Medical Examiners® (NBME®) announced three important changes to the assessment of USMLE Step 1 exams in February 2020.

1. Changing Step 1 score reporting from a three-digit numeric score to reporting only pass/fail
2. Reducing the allowable number of exam attempts on each Step or Step Component from six to four; and
3. Requiring all examinees to successfully pass Step 1 as a prerequisite for taking Step 2 Clinical Skills

A numeric score will continue to be reported for Step 2 Clinical Knowledge (CK) and Step 3. Step 2 Clinical Skills (CS) will continue to be reported as Pass/Fail. According to the NBME® this policy will take effect no earlier than January 1, 2022 with further details to follow later this year.

Among American students USMLE Step 1 has a 95% pass rate. Some hospitals receive many applications for electives and choose to use STEP 1 scores as thresholds for who can apply, sometimes in combination with written applications.

If you want to apply to a residency after graduation, it can be useful to look at the The National Resident Matching Program (NRMP) for published statistics on the average STEP 2 scores of successful applicants by specialty. Further breakdowns of other characteristics, like number of research papers published and number of interviews, are also available. These scores can be a guide for goal-setting. It should be noted that most residency programs' admission policies make it clear that STEP 1 is highly valued as a screening tool, but is not the be all and end all of your application. References, interviews, and research, among other factors, are considered too.

According to the NRMP, International Medical Graduates (IMGs) who are successful in matching to their preferred specialty are more likely to:

• Rank more programs within their preferred specialty (by getting interviews)
• Have higher USMLE Step 1 and Step 2 CK (written part of STEP 2) scores
• Be U.S. citizens” – “Charting Outcomes in the Match 2018” emphasis added

As the recent changes to the exams, most notably the Pass/Fail policy for the Step 1 exam, will take effect after January 1, 2022, for your reference these are the average STEP 1 scores of international graduates for each specialty:

*N/A means there were not enough applicants in this category to make statistical inferences

What happens after STEP 1?

The second part of the USMLE is (STEP 2) stay tuned for our upcoming article preparing for USMLE Step 2.

Step 2 is split into an OSCE style exam and a written MCQ as is the third part. These can be completed during the clinical years and after graduation from medical school respectively.

STEP 2 assesses students on content from core rotations (medicine, surgery, paediatrics, OBGYN, and psychiatry) and should not be taken before you have completed all of these. This may be in your final year in Australia.

It should be noted that not all hospitals in the U.S. require a student to pass STEP 1 in order to complete an elective there. Secondly, if you wish to apply for residency, you have to complete STEP 1 and the two parts of STEP 2.

STEP 3 can be completed during your first year of residency training if you are successful.

In addition to your STEP 1 score, your applications for interviews with training programs will be based on your personal statement, CV (research and otherwise), references, and how much clinical experience you have in the U.S. (if you are an international medical student or graduate).

Therefore, you should aim to complete some electives in the U.S. especially in your chosen specialty and get letters of recommendation from clinicians, such as department heads while in The States.

Once you graduate it is significantly harder to undergo electives and get references from U.S. clinicians due to the differences in the training systems compared to Australia.

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