USMLE Step 1 Experience

The night before the exam, I slept a total of 2-3 hours. After midnight, my mind was racing with everything I learned over the last few weeks. It’s like I was consciously consolidating information; my heart was racing and I had a horrible headache. Why my brain chose to sacrifice precious sleep the night before this exam is beyond me. I’m just glad I made it through. 😯


USMLE Step 1 has 322 multiple choice questions – I would say about 1/3rd were “gimmies” (straight from First Aid, Goljan, and UWorld). A handful were topics I had never reviewed in detail (the specific constituents of the P450 system… like CYP3A4). The rest were standard, NBME-type questions.

The test had more immunology and musculoskeletal than I was expecting but less biochemistry. I had 5-6 questions which required headphones (heart auscultation) and less than ten questions which required calculations (mostly epidemiology). There were some epidemiological graphs which I had difficulty interpreting, but the radiographic images, gross specimens, and path slides were fair. Step 1 also loves HIV-related questions.

In preparation for Step 1, I used First Aid, USMLE World Question bank, NBMEs 1-7 + any questions people posted on forums, BRS Physio, chapters 1-7 of Robbins, and good ‘ol Papi Goljan. Between First Aid and UWorld alone, the exam was manageable; however, Goljan’s high yields definitely helped me on a few questions, and some questions were very reminiscent of the NBMEs I completed.

My advice is to focus on First Aid and do thousands of questions (UWorld + NBMEs first).


There are two timers – one for the current section and another with the overall day timing. There are 8 hours to finish seven, 1-hour long sections. Remaining time will automatically be added to your break time if you finish early. My plan was to do all the questions straight through. At the end of the section, I would quickly go back through and remind myself why I picked each answer and rework every calculation (sensitivity, positive predictive values, Hardy-Weinberg, etc.) This actually saved me from committing a silly mistake (0.25% is not 0.25, it’s 0.0025). Take that, Hardy Weinberg! 😉

My timing was roughly the following:

  • Section 1: 35 minutes
  • Section 2: 40 minutes – five minute break afterwards.
  • Section 3: 60 minutes – a couple HIV-related questions were the bane of my existence. This was definitely the most difficult section for me. Needed a ten minute break to recover… and eat a Clif Bar
  • Section 4: 40 minutes
  • Section 5: 40 minutes – ten minute break to stretch and eat a granola bar.
  • Section 6: 50 minutes – another hard section, but Goljan and some of my shelf exams bailed me out. Took a five minute break to wake myself up.
  • Section 7: 50 minutes

Overall, I finished the exam with 2.5 hours left. The facility was great, water fountains and restrooms were close by, and there was no delay signing in/out of the testing room.


This section has absolutely no purpose short of its title.

  1. We have two kidneys. That’s the only thing I have ever been confident about in renal.
  2. Sarcoidosis and TB can cause everything – weather changes, stock market crashes, and less commonly, hilar lymphadenopathy.
  3. The answer is never lupus. Until it is.


Undoubtedly, one of the best things about this profession is the amount of information we can bestow on one another – I have so many people to credit for my training and preparation for this exam. I’m thankful for the pediatric surgeon who explained GI midgut rotations using tai-chi-enhanced embryology lectures… for our legendary histology professor who never let me forget that eosinophils look like ballet shoes and basophils like bull testicles… for the ob/gyn resident who empowered me to look up Gartner’s duct cysts after incidentally finding one on a pelvic exam… for the GI specialist who showed me ulcerative colitis on sigmoidoscopy. These were all things I encountered on the exam, and there are so many other professors and colleagues who taught me tidbits which came in handy. I’m nervous about getting my results, but ecstatic that this milestone is finally over! 🙂

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  1. Hey Rishi,
    I had a quick question. Why anesthesiology instead of neurosurgery? Why the change? Thanks in advance.

  2. Hi…

    What resource do you suggest for cell and molecular bio?
    Also, if one wants to practise Qs in which a experiment is conducted on a mice for Genetics section… where can one look?

    How was the length of Q on your exam… and your actually finished sections in 10 minutes… wow.

    Looking forward to the reply. Thanks.

    • I would recommend chapters 1 – 7 of Robbin’s Pathologic Basis of Disease for cell biology information. Questions were usually two to four sentences in length.

  3. Rishi; if you do not mind me asking, what did you make on USMLE Step 1 and 2? And what specialty are you interested in?

    • Hey Erin! I won’t give an exact number, but I did better than Baylor Med’s average last year (244); I haven’t taken Step 2 yet. As far as specialty, I’ll be applying for anesthesiology this fall and plan on pursuing two fellowships – pain and pediatrics. Thanks for the inquiry! 🙂

      • First of all, a huge congrats to you! 🙂 But wow, 244 is “average”?! I hope this is a typo? I’m hoping for anesthesiology too, and thought 230 would be more than enough. Now I’m not so sure… 🙁

        • Thanks Pat! Baylor Med’s average Step 1 scores are in that ballpark from year-to-year; we’ve got an awesome curriculum and excellent professors to thank for that. =)

          Just keep in mind that I’m referring to the average of our CLASS… not just the people who applied to anesthesiology.

  4. Hey hii… Congrats on getting done with exam and good luck for u r result.
    i have my Step 1 shortly and i have recently solved NBME 11/12 and 13 i felt 13 was easier compared to the other 2[11/12] Which NBME u think relates to the main exam?
    I really appreciate u r reply

    • I really don’t have a good way of correlating NBMEs to the real Step 1 (especially since I didn’t do NBMEs 11 – 13) – my advice is to do as many of them as you can. It certainly can’t hurt, and I know I recognized a few questions which were very similar to items I encountered on NBMEs 1 – 7.

      Best of luck, Jyothi!! 🙂

  5. Congratulations!!!
    Thank you for documenting this part of your med school journey, I’m taking Step 1 in June and all these posts have been a great encouragement.

  6. So proud of you brother! I have checked your website constantly as you have gone through your Step 1 Journey and I have thoroughly enjoyed reading your posts! Thank you for all your advice and CONGRATULATIONS!!!


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