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Should You Take Step 2 CK Before Step 1 (or Can You Study for Both)?

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by Alec Palmerton, MD in Step 1 Pass-Fail

With Step 1 being pass-fail, you may be wondering: “should I take Step 2 CK before Step 1?” Step 2 CK is now the only scored USMLE. As such, it will inevitably receive more interest from residency programs. If Step 2 CK is the “new Step 1”, should you take it first?

I work with many students in their preparations for both Step 1 and Step 2 CK. This means I’ve been able to see their progression as they move from their first USMLE (usually Step 1) to the next. While most have chosen to take Step 1 first, a handful has decided to focus on Step 2 CK first – often with good results.

With the move to pass-fail Step 1, the question of order becomes even more pressing. Before, if you had a low Step 1 score, you could always change your approach and hope for a better Step 2 CK score. Now with Step 1 pass-fail, the stakes are higher.

In this article, we will address:

  • The pros and cons of taking Step 1 vs. Step 2 CK first
  • How much overlap there is between the two tests
  • How to study so you can maximize your Step 2 CK score, even if you haven’t taken Step 1 yet
  • Whether you can study for Step 1 and Step 2 CK simultaneously
  • Finally, my recommendations on the best approach

Reasons to Take Step 1 First

Pro: Solidify Key Concepts on Step 1 Before Applying Them on Step 2 CK

The Step 1 material comes before Step 2 CK in medical school for a reason. Physiology, pharmacology, pathology, histology, and the other subjects are fundamental to clinical medicine. Trying to learn about amniotic fluid embolism before understanding cardiology, pulmonology, and hematology is a disaster waiting to happen. Yes, you can memorize “tachycardia, tachypnea, high A-a gradient and possible cardiovascular collapse.” But without a solid understanding of basic physiology, you’ll flounder when faced with a vignette, let alone an actual patient.

Studying for Step 1 first will allow you to build the foundation necessary to do well on Step 2 CK. It’s not surprising, then, that Step 1 scores are among the single-best predictors of one’s Step 2 CK score in every study I’ve seen.

Pro: Maximize Study Time Before Taking Step 2 CK

Some people believe that Step 1 and Step 2 CK are completely different tests. I disagree. While a small portion of Step 1 is Step 1-specific, most of it will overlap with Step 2 CK. Think you can forget about the aforementioned genetics, immunology, and biochemistry? Guess again. Even some of the most hardcore basic science topics can make a reappearance on Step 2 CK, particularly in the pediatrics section.

Students in their pediatrics rotation are shocked they still need to remember immunodeficiencies, biochemical pathways, and lysosomal storage diseases. So, what is different in the genetics, biochemistry, and immunology content of Step 1 vs. Step 2 CK? On Step 1, basic science material may be tested more directly. In contrast, for Step 2 CK, questions often relate to the clinical applications of basic science concepts. A pediatrics biochemistry question is unlikely to show you a list of biochemical intermediates and ask which enzyme is defective. Instead, you will be presented with a 6-month-old infant who is seizing after getting a viral GI infection. Both deal with the same pathways and foundation – the ways they test you on them are the only things that differ.

These things feel overwhelming if you’re trying to learn them well for Step 2 CK for the first time. By mastering these first for Step 1 first – and utilizing an effective strategy to remember them – you’ll be able to stand out on the basic science topics that others struggle on.

Pro: More Time to Practice and Get Used to the USMLE Format

The USMLE questions follow a very specific format not found in many — or even any — other exams. It is common to see people who were at the top of their medical school class struggle to even be average on the USMLEs. These previously successful students prepare like they have in the past, but struggle to get results that are even close to the same.

There are many reasons for this discrepancy in performance. (To read more about how the NBME writes USMLE and Shelf questions, read this LINK HERE). Some of the most basic differences that make USMLEs harder for many include:

  • The USMLEs Use Two-Step Reasoning
  • The USMLEs Test Your Ability to Apply Critical Concepts
  • Step 1 and Step 2 CK Aren’t About Memorizing List of Facts

If you’re used to memorization-heavy tests, it takes time to re-adjust and learn the secrets of the USMLEs. As such, taking Step 1 is a great way to get your feet wet and learn the format in a lower-stakes environment.

Reasons to Take Step 2 CK First

Pro: Focus on the More Important Test (Step 2 CK) First

With Step 1 no longer having a score available to residency programs, Step 2 CK takes center stage. Residencies screening applicants will have no choice but to use it to sort through the hundreds of applications they receive.

Here is a sampling of some of the views shared by program directors:

  • The majority of orthopaedic (89.7%) and IM (69.6%) PD respondents believe that Step 1 will become less important when it transitions to pass/fail
  • In a survey of dermatology PDs, 86.0% (49/57) indicated they would increase their emphasis on Step 2 CK.
  • 2% (43/55) of these PDs also reported they would begin requiring Step 2 CK for all applicants.
  • One survey of internal medicine PDs, 87.8% said Step 2 CK scores will be more important
  • 9% of these orthopedic surgery PDs said Step 2 CK will become more important

By doing Step 2 CK first, you can put your focus on the more heavily weighted exam. As the saying goes, “chase one rabbit, catch it. Chase two, catch neither.”

Pro: Step 2 CK May Be More Familiar and Comfortable

Another positive for Step 2 CK for you may be that the material is more familiar. This is especially true for IMGs or those whose basic science curriculum was weak and/or long ago. Studying for the USMLEs is challenging. Studying microbiology, genetics, biochemistry, and other basic science topics may make you want to tear your hair out.

If you’re a procrastinator like me, the more unpleasant the task, the more likely I am to delay it. Especially if it’s been a while and/or you never learned the material particularly well, Step 1 may feel much more painful. As such, it may be better to start with Step 2 CK.

Step 2 CK Material May Be Super Fresh (You Just Did Clinicals)

Some of you may even be in your clinical rotations and haven’t taken Step 1. If that is true, it is very tempting to take your Step 2 CK while the information is still fresh. Many people find it difficult to do things like spaced repetition/Anki on rotations. If that describes you – and/or you forget a lot of what you learn after every rotation – this may sway you to try and take Step 2 CK before Step 1.

Step 1 vs. Step 2 CK First: Can You Study for Both Simultaneously?

Ultimately, the decision to take Step 2 CK before Step 1 is up to you. If I had to choose one to study for first? Given the importance of being at your best on Step 2 CK, I would recommend taking Step 1 first. You can learn the format of the USMLEs in a lower-stakes setting. In addition, most of what you learn for Step 1 will form the foundation of a strong Step 2 CK.

But what if Step 1 vs. Step 2 CK first is a false choice? What if there were a way to study for Step 2 CK and Step 1 simultaneously? In fact, yes, you can study for Step 2 CK and Step 1 at the same time.

How? By studying for Step 2 CK from the beginning – but mastering the basic science, as well. In other words, you learn both the entire spectrum – basic pathophysiology all the way through the presentation/management – for each disease.

Master Everything – From the Basic Pathophysiology to the Presentation/Management and You’ll Be Ready for Any USMLE

For example, you need to understand Von Gierke disease for both Step 1 and Step 2 CK. Rather than try and memorize the biochemical pathways for glycogenolysis/gluconeogenesis, connect the pathophysiology with the presentation. In a child with Von Gierke, because of the glucose-6-phosphatase deficiency, they cannot convert glucose-6-phosphate to glucose. As such, the glucose-6-phosphate is “trapped” inside their liver. Thus, during a short fast, glycogenolysis/gluconeogenesis would be unable to furnish supplemental glucose. The resulting hypoglycemia would be pronounced, often in infancy, leading to things like lethargy or even seizures, particularly in times when cell glucose utilization is high. (E.g., a young infant having hypoglycemic seizures during a GI viral illness).

Does the basic science help you understand the presentation and management of disease? Absolutely. If you have some flexibility in your timing, you should strongly consider studying for Step 2 CK nominally – but making sure that you master the basic science foundations underpinning it.

To ensure you can pass Step 1, be sure to take Step 1 NBMEs periodically. Because there is so much overlap between Step 1 and Step 2 CK, mastering the Step 2 CK material should lead to regular improvements in your Step 1 score. Whenever you’re comfortably above passing, you can take Step 1. Then, once you’ve passed, you can return your attention to Step 2 CK.

Bottom Line: Should You Take Step 2 CK Before Step 1?

Have you ever heard the phrase, “all overnight success takes about 10 years”? That, in a nutshell, is how you should approach your Step 2 CK preparations.

Yes, your dedicated study period may be as short as a month or two. But your preparation in the months/years before that is what will make the difference. Whether that deliberate preparation involves taking Step 2 CK or Step 1 first (or both simultaneously), the key is mastery – not memorization. Ultimately, mastery of the basic science on Step 1 will accelerate and deepen your Step 2 CK abilities.

In fact, this synergy between the basic and clinical sciences is the reason why we don’t separate our Online Course into Step 1 and Step 2 CK material. Rather, we teach all diseases the same way – using the basic science to explain the clinical presentations and management. By mastering everything – from the pathogenesis to the presentation and management – will help you with whatever the USMLEs can throw at you.

Yousmle Helps You Be At Your Best on Step 2 CK…Even If You Haven’t Taken Step 1

Yousmle’s bread and butter is helping students be at their best for Step 2 CK by helping them develop the skills to master the concepts and applications needed for Step 2 CK. Many of these students have underperformed in med school previously and had below-average Step 1 scores. In these cases of prior underperformance, they had to re-learn a lot of the Step 1 material before their Step 2 CK performance took off.

For example:

  • Minali, who had a below-average Step 1 score but then scored 260+ on Step 2 CK. She’s a resident at Harvard, and credits the work in building her foundation with her turnaround.

If you want to prepare today to make sure you are at your best for Step 2 CK, schedule a free consultation. We’ll walk you through what you can do to be at your peak for Step 2 CK, even if you haven’t started studying for Step 1 yet.

What do you think? Do you think people should study for Step 2 CK first? Step 1? How will you make your decision? Let us know in the comments!

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.