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Use the Latest USMLE Step 1 Changes to Maximize Your Score

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by Alec Palmerton, MD in Uncategorized

The USMLE just announced major changes to the Step 1 format. This announcement continues a trend over the last several years of the exam having more and longer clinical vignettes, which require greater amounts of time to answer, and fewer questions that can be answered by simple memorization or recall.

You can read more about the upcoming changes to Step 1 on the USMLE website.

Beginning the week of May 9, 2016, the number of questions for the entire exam will decrease to 280 from 308. The amount of time per block, and total amount of time for the exam will remain unchanged, meaning that the number of items per block will decrease from 44 to 40.

The scores will remain comparable, and because of the transition, the release of scores will be later than normal, with the planned release of scores for examinees between May 9 through late June to be Wednesday, July 13, 2016.

When should you take your exam?

If for some reason you absolutely must have your score before July 13, 2016, they recommend that you take Step 1 no later than May 7, 2016.

Should you take your exam sooner, to try to take advantage of the old format?

On the surface, it may seem like the exam is changing a great deal. However, if you look more closely, this change merely represents the next step in a gradual transition to having more questions that are longer clinical vignettes, that force you to understand concepts, rather than simply memorizing information.

Think about the “Rapid Review” section in First Aid, where complex medical conditions or boiled down to simple phrases, were things like aortic stenosis becomes “ejection click,” and chloramphenicol becomes “gray baby.”These questions already were becoming more and more rare, so it simply puts an even greater emphasis on understanding clinical vignettes, and using your knowledge to integrate and apply across disciplines.

What is the best way to prepare for the exam, regardless of when you will be taking the exam?

Support the website below to learn my #1 tip for how to approach ANY clinical vignette, and the #1 mistake students make on Step 1 questions (HINT: it will become even more important with the new test changes).

When I began my dedicated Step 1 study period, I’ll be honest: my knowledge was pretty solid.  I’d been using Anki for about 1.5 years, and I had gotten the concept of pathogenesis to presentation down.  I’d been diligent about doing my cards and had done relatively well in my medical school classes at Stanford.  Going in, I was guardedly confident.

So did I coast through my NBMEs on the way to scoring 270?

Heck no!

When I took my first NBME (and virtually every practice test after that), I was shocked looking back over the answers how many questions I was missing to which I had actually known the answer.

Why was I missing so many questions in topics I thought I knew well?

It turns out, I wasn’t missing questions so much for a lack of knowledge (although there were a number of those, as well).  I was missing them because I didn’t understand what the question stem was telling me.

The concept of “just read and re-read First Aid over and over” had been so ingrained in me, that when I started out, all I was doing was searching for “buzz words.”  Vignettes with the phrase “gray baby,” “worst headache of his life,” and “young athlete falls down on basketball court suddenly,” immediately triggered the appropriate answers (“chloramphenicol,” “subarachnoid hemorrhage,” and “congenital hypertrophic cardiomyopathy”).

What I didn’t realize was that these kinds of easy questions, while they existed, were few and far between.  Instead, the majority of questions I missed were because I wasn’t interpreting the question correctly.  When the sentence said, “56 year old man w/ hypertension and diabetes has episode of severe chest pain.  2 weeks later, he comes to his doctor, who notices that he now has jugular venous distension, and clear lungs,” I literally thought they meant that the guy had chest pain w/ jugular venous distension and clear lungs.  Without the buzz words, I was lost, and just moved on.

Instead, what they really meant was, “Middle aged male has 2 cardiovascular risk factors, suffers a myocardial infarction 2 weeks ago, and now has isolated right-sided heart failure (presumably because he had a right-sided myocardial infarction).”

When that veil had been lifted, my NBME scores took off, going from 230s to 250s, then 260s, and ultimately my final score of 270!

So, what can YOU learn from my mistakes?

1) For every sentence, figure out what the point is
Particularly for Step 1, no sentence is there by accident, and they are NOT trying to trick you.  If you think a sentence is there as filler, check again, since there very well might be something you’re missing. For students I tutor, whether they ended up with 260+ or had been simply struggling to pass, this is often the biggest thing holding their score back.

2) Slow down so you read each vignette only once
The second biggest mistake I made with QBanks/NBMEs was that I read so quickly I didn’t give myself time to process the information.  As a result, I ended up wasting gobs of time re-reading passages.  Make it your goal to read each vignette once, and I promise even the slowest reader will have enough time to finish their blocks.

3) Check out the Table of Contents for others of my best tips on how to stay sane while efficiently increasing your USMLE/COMLEX/Shelf scores!


  1. Aisha Z says:

    What NBMEs would you suggest for the post May 9 exam? NBME 18 is the latest one out and I definitely plan on taking that, however, I would want to take a couple of more just for practice and monitoring improvement. I am thinking of taking around 4, starting with 13, followed by 15 and 17 as a ‘mock exam’, and finally NBME 18 two days prior to the real thing, just because it’s the latest one available

    Would the older NBME’s still predict as accurately?

    1. Yousmle says:

      I believe they should although I’d tend to believe the more recent ones, since as you point out they were released more recently.

  2. Jy says:

    Hi Alec, I hope you’re doing well.
    I just checked the updated brochure on “USMLE step 1 sample items Booklet” in the link you provided above from the website, and the questions still seem quite similar to those in uworld qbank. Do you feel there has been a drastic change or it is insignificant? Also, it is mentioned that the scores are comparable to the old format of 308 qs, but I am wondering, for instance, if someone scored 240 in the new format, how is 240/280 comparable to 240/308? I was not very clear about that. Will the score be scaled upwards to match the former 308 pattern?

    Thank you.

    1. Yousmle says:

      Great question – the scores are scaled, so a 240 on the old exam should be worth the same as a 240 on the new one. Remember, a 240 doesn’t mean you got 240 questions right – it’s scaled to the difficulty to the test, and is supposed to be comparable across test-taking times. I don’t think it’ll be a drastic change, rather it’ll be another in a gradual shift towards more complex, clinical vignettes (i.e. more like Step 2 CK/Step 3), less like the rote-memorization approach found in NBME 7/earlier or in the FA Rapid Review section.

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Want FREE Cardiology Flashcards?

Cardiology is key for impressive USMLE scores. Master cardiology from a Harvard-trained anesthesiologist who scored USMLE 270 with these 130+ high-yield flash cards. You’ll be begging for cardio questions - even if vitals make you queasy.