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How to Build USMLE Test-Taking Stamina

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by Alec Palmerton, MD in Plan

How do you build stamina for the USMLEs, 8+ hour exams? What can you do to make sure you’re not exhausted by the end or even by the last question of each block? How can you maintain your concentration without getting drained?

This article will discuss how to build up stamina for your USMLEs. These are some of the lengthiest exams you have ever taken. Therefore, knowing how to maintain your energy and focus throughout the 8+ hours is critical.

You will learn:

  • How long each USMLE is,
  • The amount of break time you have to play with (and how to get more),
  • Ways you can improve your stamina with how you study,
  • The best snacks for an 8+ hour exam,
  • How to dose caffeine in small increments, so you don’t crash, and
  • Much, much more

How Long Are the USMLEs

The USMLEs are marathon exams. Step 1 is eight hours – seven one-hour blocks of questions and one hour of break time. (More on this later). Step 2 CK is even longer – nine hours! Step 2 CK has eight one-hour blocks of questions and the same one-hour of break time.

Here is a summary of the maximum available break time for each USMLE if you skip the tutorials. Omitting the 15-minute tutorial adds that 15 minutes to your break time, so you end up with 45+15 = 60 minutes total of break time:

  • Step 1: 60 minutes for 7 hours of MCQs (8 hours total)
  • Step 2 CK: 60 minutes for 8 hours of MCQs (9 hours total)
  • Step 3:
    • Day 1: 50 minutes for 6 hours MCQs (~ 7 hours total)
    • Day 2: 57 minutes for 4.5 hours MCQs + ~3.5 hours case simulations (~ 9 hours total)

Use Your Break Time Effectively

The first step in building your USMLE stamina is effectively managing your break time. Burning your break time early will make it harder to recover later when you’re running on fumes.

We’ve discussed our recommended break time strategy here. For more specifics on Step 1, Step 2 CK, and Step 3.

The short answer is that you should reserve your breaks for later in the test when you’re more tired. Often people won’t need a pause between the first and second blocks, for example.

If you need to rest early in your exam, you can simply take a break but sit at your desk. Without the time consumed with checking in and out, you can take a much shorter break, which can help refresh you for your next block.

For more on the best USMLE break time strategy, see this article.

Problems with Stamina (and Timing) Are Alleviated with a Stronger Foundation

Perhaps the most important thing to improving your stamina is to make the test less draining. What do I mean?

Have you ever tried to read something in a language you barely understand? Do you remember how exhausting it was?

The same thing is true whenever our brains are strained by what they are trying to do. So, in simplistic terms, the more difficult the test is for you, the more exhausting it will be.

The best way to make the test more effortless is to build a strong foundation. A strong foundation requires two things:

  • Flexible application of concepts
  • Intuitive recognition of clinical scenarios
Build a Strong Foundation Around Concepts

There are broadly two ways people study for the USMLEs. The first is that people do questions and memorize the details of the questions they got wrong. Then, they’ll make detailed flashcards and pore over the minutiae. Deep down, these people are hoping that pattern recognition and buzzwords will improve their scores.

The second group focuses on mastery – understanding the conditions rather than memorizing the details. For example, these foundation-builders will understand that asthma leads to bronchoconstriction, which will increase the resistance and thus the likelihood of turbulent flow. Instead of memorizing that there is air-trapping, they will have made sense of it. Rather than cramming that asthmatics have a worse cough, they’ll understand that the inflammatory process behind asthma increases the sensitivity of the airways and thus enhance the cough reflex.

Because of this deeper understanding, it will make total sense that one of the treatments for asthma is inhaled glucocorticoids. In addition, since inflammation drives so many cases of asthma, an anti-inflammatory makes complete sense.

USMLEs: Concepts >> Details

The USMLEs are famous for keeping the concepts the same but changing the details. To the memorizer, each USMLE question is different from what they’ve seen in UWorld or other QBanks. As a result, they are more likely to be confused and tell their friends, “the USMLEs are nothing like what I saw in my NBMEs and QBanks!” The memorizers are also more likely to panic, get stressed, and have poor USMLE test-taking stamina.

In contrast, the people who understand the conditions will be able to spot the same concepts when the details change. In addition, they will be much less confused by the wrinkles that the test-writers throw in. Most importantly, doing questions will feel more enjoyable – some students have described it as solving a puzzle. Decreasing the stress – and increasing the enjoyment – on test day is one of the best ways to improve your USMLE stamina.

Address Test-Taking Anxiety

The less taxing each question is – and the more enjoyment you get from the process – the more energy you will feel. As crazy as it sounds, I’ve heard from well-prepared students that they thought the test was even fun!

But each question will feel like a tremendous burden the more anxious we feel. Anxiety is rampant in our society – and particularly among medical students. Flow is the feeling of being completely immersed in an activity, so we lose ourselves. It has myriad benefits, including improved energy, focus, and performance. Anxiety is in many ways the opposite – we are so disconnected from the situation and “in our heads.”

Anxiety often builds over years and years, and there is no easy fix. The more you can address the root causes of stress, the better your USMLE preparation and stamina. I’ve found techniques like EMDR particularly helpful both for myself and the students I work with.

For more on how to cope with test-taking anxiety, see this article.

Eat the Right Snacks

A critical element to USMLE stamina is your snack/lunch strategy. No amount of preparation will help if you have a sugar crash on test day. The snacks and lunch you eat will significantly impact your sustained focus during the test. From our article on what to bring on test day.

Everyone will preference snacks for Step 1, Step 2 CK, or Step 3. Our recommendations are things that:

    1. Are high in protein to limit sugar highs/crashes,
    2. Won’t make a big mess,
    3. Don’t have a lot of liquid to prevent too many bathroom breaks

To that end, we recommend things like nuts in individual packages. For example, you can have individual plastic bags with mixed nuts. As a pro tip, make enough individual bags for each break you expect to take – and number the bag with which break it is. (E.g., “Break #1,” “Break #2,” etc.).

By pre-making/-labeling each snack bag, you don’t even have to think about what/when you’ll eat each snack. Even better, since taking an 8+ hour exam can be disorienting, having labeled snack bags can help you track how many exam blocks you have left.

Consider Dosing Your Caffeine with Chocolate Covered Espresso Beans

Another question is how to get your caffeine fix on test day. When break time is limited, and stakes are high, you may be wondering if coffee or other liquid forms of caffeine are wise. One way around the need to get caffeine from a cup of coffee is to use chocolate-covered espresso beans. (

Each bean has ~10 mg of caffeine (a cup of coffee has ~100 mg). In addition, the beans aren’t liquid, so that they will require fewer bathroom runs. Plus, because each bean has a fraction of the caffeine of a cup of coffee, it is easier to titrate the amount necessary to keep you focused without getting too jittery/crashing later.

Do a Full-Length (or Longer) Practice

Finally, to improve your USMLE stamina, consider taking a full-length practice test beforehand. Remember:

  • Step 1: 7 blocks (each one hour) + 60 minutes total break time = 8 hours total
  • Step 2 CK: 8 blocks (each one hour) + 60 minutes total break time = 9 hours total

Nothing can prepare you perfectly for an 8+ hour exam, especially one with such high stakes. That said, you CAN do a practice run 1-2 weeks before your exam. This practice run consists of:

  • One 4-block exam (e.g., a UWSA or four blocks of a QBank), followed by
  • One NBME

Note that if you do this, your test will be LONGER than Step 1 (and about the same length as Step 2 CK). Remember, Step 1 only has seven blocks of 40 questions – you will be “overtraining.”

What if I Want to Take a Regular Length Step 1 Practice Run?

If you prefer to NOT overtrain for Step 1, and take a test with the same length, simply do two blocks of a QBank (e.g., UWorld) before doing an NBME. Why only two blocks? Because Step 1 NBMEs still have 50 questions in each of the four blocks; Step 1 will have 40 questions/block. The Step 1 NBMEs, thus, still have 200 questions as of this writing, meaning that you would only have to do 80 questions from a QBank to simulate the real thing.

We’ve discussed our recommended break time strategy here. For more specifics on Step 1, Step 2 CK, and Step 3.

If you’re a part of the Yousmle Online Course, let us know when you plan to take your test! We will send you a care package with enough snacks for TWO tests—the first set for your practice and the second for the real deal.

Concluding Thoughts

Do you find yourself getting exhausted from doing QBank questions? Does this make you worry about your USMLE test-taking stamina? Even if you’re not struggling on your blocks, you may worry about what an eight- or nine-hour exam will feel like. This concern is even more significant when the stakes are so high.

The good news is that USMLE test-taking stamina is relatively straightforward to build. It may seem counterintuitive, but the quality of your preparation has a lot to do with your Step 1, Step 2 CK, and Step 3 stamina.

What have you found hurts your studying stamina the most? Conversely, what has been the most helpful? Let us know in the comments!

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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.