What 250+ on Step 1 or Step 2 CK Means, and How to Do It

by Alec Palmerton, MD in Plan

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Having helped others score 250+ on Step 1 and Step 2 CK, I’ve wondered: what does it take to score 250+? We’ve all heard the self-serving humble-brag. “Oh, all I did was use UWorld + First Aid.” But “do UFAP” doesn’t begin to explain a playbook for scoring 250.

My experience will surprise you. Most of us assume high USMLE scores require lots of memorization. (Spoiler: memorization is a sure-fire way to USMLE disappointment). However, although mastery is vital for high scores, even learning things well isn’t enough for a 250+ USMLE.

In this article, you will learn:

• The questions you should (and shouldn’t) ask high scorers
• Just how good is a 250+ on Step 1 or Step 2 CK?
• How a 250 compares to the average matched scores for NRMP specialties?
• The common element to scoring 250+ on any USMLE exam
• Why scoring 250+ on Step 1 usually requires high NBMEs to start
• How you can increase your Step 2 CK much more quickly (and why most people don’t)

Resources/Routine vs. Rationale

Here’s the typical Boards prep conversation:

• Me: Hey, how did you get such a high score?
• Friend: Oh my gosh, let me tell you! First, I used this great resource called UWorld. Then I used First Aid. I put everything into Anki. After about 4 weeks, my scores were 250+.
• Me: Wow, that’s amazing. But what did you do to score 250+?
• Friend: Well, in the morning, I would do my Anki cards. Then I’d do UWorld for 30 minutes. I’d write down my wrong answers. Then I’d study my organ system for the day by reading First Aid. Then I’d do more UWorld. I’d do this every day until…

What do you notice? When people describe how they scored so high, they’ll tell you two things:

1. The resources they used, and
2. Their routine

Resources and routines can be helpful. However, these tell only a small part of the story behind high Step 1 and Step 2 CK scores.

Follow the Proper Rationale for Higher Scores

What do I mean? Let’s imagine we had the same conversation, but with Picasso. We asked him how he painted such masterpieces. What if all he told us was:

1. The paint brands he used (resources), and
2. His daily routine?

We’d be missing everything behind his genius!

Instead, you’d need to get inside his head. What techniques did he use? What was his rationale for painting the way he did? How did he choose his subjects?

Learning how to study is no different. When you look at how someone achieved a 250+, you need to understand her approach. Knowing her resources or schedule may be useful. However, it is much more illustrative to understand her rationale.

How Hard is it to Score 250+ on Step 1 or Step 2 CK?

Everyone hears that a USMLE score of 250+ “opens doors.” But what exactly does the mythical 250 threshold mean?

The NBME reports average scores for Step 1, Step 2 CK, and Step 3 for first-time test-takers. This is their 2018 report, which reports the percentiles for various USMLE scores between January 1, 2015 – December 31, 2017:

You can see that for Step 1, a 250+ is above the 84th %ile for this large cohort. Similarly, for Step 2 CK, a 250+ is above the 65%ile. In short, a 250+ is quite an impressive score, particularly for Step 1.

But how important is your USMLE score? Next, we’ll see how valuable a 250+ is when you apply to residency.

A 250+ is a Big Deal for Residency Applications

USMLE Step 1 and Step 2 CK scores are consistently ranked as two of the most important criteria for getting a residency interview. Every two years, the NRMP (the organization that administers the “Match”) surveys residency program directors. The list of questions is extensive. A massive point of interest is how program directors screen applicants for interviews. (Hint: a big part of it is your USMLE scores).

(To read Get Into a Top Residency: 5 Things You Need to Know, click here.)

Here are the top 5 factors for receiving an interview invitation, from the 2018 survey.

1. USMLE Step 1/COMLEX Level 1 score
2. Letters of recommendation in the specialty
3. Medical Student Performance Evaluation (MSPE/Dean’s Letter)
4. USMLE Step 2 CK/COMLEX Level 2 CE score
5. Personal Statement

Notice how many of these things are scores and grades. Remember, program directors are busy, so they use things like Boards scores to “screen” applicants.

High USMLE scores are also important for matching into your desired specialty. Below are the average USMLE scores by specialty by matched and unmatched US applicants.

The bottom line? USMLE scores are important for residency applications. But how to get that mythical 250+?

To get a 250+ on Step 1 or Step 2 CK: Avoid Unforced Errors

Most people assume there’s a linear correlation between the amount learned and their final score. This is wrong. Instead, knowledge will help you to a certain point. To get over the hump, you have to stop making unforced errors.

Try this the next time you do a QBank block. Count the number of questions you missed due to a lack of factual knowledge. For example, items you missed because you forgot Listeria is Gram +. Or what exactly a “right-dominant heart” is.

My guess? The number of questions you miss from a lack of factual knowledge adds up to less than 50%.

But what about the remaining questions? Those other missed questions have little to do with knowledge. Think about that. You may have noticed you missed some items because you misunderstood the question. Or that you fixated on the distant breath sounds but ignored the chest pain. And how many times have you gotten between two answers, but struggle to eliminate the wrong one?

I call these “interpretation errors,” and they add up. In fact, for most people, they add up to 50% of the points you’re missing on your test.

It’s simple. Knowing every fact on your test is impossible. So you’re going to miss a certain number of questions no matter what. However, the more “unforced errors” you make, the lower your chances of 250+.

To score 250+ on Step 1 or Step 2 CK, you need to avoid unforced errors

Question Interpretation = Same Knowledge, Higher Scores

You may think that these “unforced errors” are unavoidable, as well. However, you’d be wrong. After learning question interpretation in the Online Course, students’ scores can improve immediately. “Not being a good test taker” often means “not knowing how to approach questions properly.”

(Note: the Yousmle Online Course teaches you Boards-relevant mastery of topics. This includes mastering each subject’s common pitfalls so you can get a higher score in less time.)

Teaching how to read a question is counter to what most people do. (Including commercial courses). Instead, most of us focus on learning more and more material. Why? Because to get to the 220-230s, you still need to understand a lot of content. Our scores kept going up when we mastered more and more material. Why would we change our strategy now?

However, past the 230s, much of your improvement comes from eliminating careless mistakes. You can have the world’s best knowledge, but if you get questions wrong on subjects you know, it’ll be hard to score 250+.

But what about advice that is specific to each test? Next, we will discuss what makes Step 1 different, and why having a high baseline score is essential.

(To read The Secret to Scoring 250/260+ You Can Learn Right Now: Question Interpretation, click here).

Scoring 250+ on Step 1: it’s all about the mastery, baby

The NBME, the writers of the USMLE, make their objectives very clear. They want you to master and understand the material. They actively discourage memorizers by using clinical vignettes. Here’s a sampling from the NBME guide they give to question-writers:

• “Questions should NOT focus on the direct assessment of isolated facts.”
• “Avoid asking about the leading cause of death in some subpopulation; instead, focus on the application of this knowledge.”
• “The NBME decided that it was not important to assess whether students know definitions; instead, the goal became assessment of whether or not test-takers could apply ethical principles on their decisions related to patient care.”

Nowhere is this focus on mastery over memorization more apparent than on Step 1. Gone are the days when you could scan for buzz-words to get the question right. Now, you have to analyze passages for clinical coherence.

Step 1 250+: Understanding >> Memorization

What does this mean if you want to score 250+? You have to understand in depth large amounts of material. No more memorizing.

Practically, this means that a high Step 1 score typically requires long-term planning. Wonder why it’s so rare to see someone break 250 without starting near 220? (For reference, when I scored 270 on Step 1, I started at a 236 2 months out). Because a 250 on Step 1 requires so many things:

• In-depth knowledge of a wide variety of topics
• Reducing unforced errors with proper question interpretation
• Random “general knowledge” type skills, like converting L/min to cm^3/second

Rome wasn’t built in a day. Having excellent knowledge on a wide variety of topics can’t be done in a few months. If you want a 250+ on Step 1, your best bet is to start early.

• For How to Ensure Your USMLE Studying is “High Yield”, click here.
• To read UWorld + Anki: 5 Ways to Stop Wasting Time and Score Higher, click here.
• To see Step 1 Study Schedule for 250+ and Top Preclinical Grades, click here.

Scoring 250+ on Step 2 CK: focus on question interpretation

If Step 1 is about mastering more subjects, Step 2 CK is about their application. Sure, mastery and application are important for both exams. However, the proportions are different for each test. I’d estimate that the relative importance for each exam would be:

Step 1: 50% mastery, 50% application/interpretation
Step 2 CK: 20% mastery, 80% application/interpretation

Read through some sample Step 2 CK questions. What do you notice? First, they’re often longer. Second, they include a lot more clinical details, many of which may be irrelevant. Here’s one of the sample Step 2 CK questions from the NBME.

A previously healthy 22-year-old college student is brought to the emergency department by her parents 20 minutes after they observed her having a seizure. After the seizure, she was confused and had difficulty thinking of some words. She has had a headache, cough, and fever for 3 days treated with acetaminophen and dextromethorphan. Her temperature is 38.9°C (102°F). Neurologic examination shows diffuse hyperreflexia. On mental status examination, she is confused and has short-term memory deficits. She has difficulty naming objects and makes literal paraphasic errors. An MRI of the brain shows bitemporal hyperintensities. A lumbar puncture is done; cerebrospinal fluid analysis shows an erythrocyte count of 340/mm3, a leukocyte count of 121/mm3 (88% monocytes), and a protein concentration of 78 mg/dL. Which of the following is the most likely diagnosis?

(A) Bacterial meningitis
(B) Dextromethorphan intoxication
(C) Herpes simplex encephalitis
(D) HIV encephalopathy
(E) Reye syndrome
(F) Syphilis

Step 2 CK Questions: Applying Your Knowledge

What did you need to get this question correct? Yes, you need a good knowledge base. But to get items like this right, you need to put it together.

Did you put all of that together? Even more, could you do it in 90 seconds or less?

(The answer is HSV encephalitis, C. It favors the temporal lobes, and can cause bleeding. Bleeding causes the high RBC count on lumbar puncture (LP). Infection/bleeding can cause seizures. Because it’s a virus, LP would also show lymphocyte predominance (88% monos). She’s a college student, so has a higher likelihood of HSV exposure. The hippocampus is in the temporal lobe, hence her memory problems. And the virus/bleeding could affect neighboring areas, like the motor cortex. This would lead to UMN findings).

Mastery is still important. However, for Step 2 CK, you need to take the next step. Like a real physician, you need to put together the pieces into a coherent whole. This requires you to separate the clinical wheat from the chaff.

In short, you have to be excellent at question interpretation. The bad news? Question interpretation, like topic mastery, is challenging.

Question Interpretation = Skill

The good news? Interpretation is a skill, and as such, can be applied to a wide variety of different questions. Learning about heart failure will only help me for heart failure-related questions. However, the better I am at question interpretation, the better I will be at MOST questions.

This broad applicability explains why students can improve dramatically in a short time. Melody, who scored 226 on Step 1, skyrocketed to 260 on Step 2 CK. Her shelf exam scores jumped within a month once she improved her interpretations.

I’ve had other students improve by 60+ points in less than 3 months, from 200s to 260s. While a leap of that magnitude is rare for Step 1, for Step 2 CK it is more common. Why? Because the better your interpretations, the better your chances on every question.

Concluding Thoughts

A Step 1 or Step 2 CK score of 250+ may seem unattainable. Indeed, few people get such high USMLE scores. However, just because a high score is difficult, doesn’t mean it’s impossible.

Instead, you have to know what to focus on. The following estimates have helped me to know what to prioritize:

• Step 1 = 50% knowledge + 50% interpretation
• Step 2 CK = 20% knowledge + 80% interpretation

In other words, what you know matters. However, applying that knowledge is equally important in determining your final score.

Do you want to take the next step to master the USMLE fundamentals? Master material and question interpretation in the Yousmle Online Course. You’ll learn more in less time, for higher USMLE scores and more fulfilling careers.

Photo by Zoë Reeve.